Name
*
First Name
Last Name
Email
*
Date of Birth
MM
DD
YYYY
Age
Phone
(###)
###
####
Address
Occupation
Relationship Status
How did you hear about natural hormone replacement?
Do you feel somewhat knowledgeable about natural hormone replacement?
What is your objective for natural hormone replacement?
Describe your general health
Height
Weight
Waist
Medical Conditions
Drug/Food/Other Allergies
List of current medications
Vitamins/Herbs/Supplements
Have you recently had any of the following tests?
Describe your daily diet
Do you exercise regularly?
Do you use tobacco products?
Did you previously use tobacco products?
Do you drink alcohol?
If so, how many days per week?
If no to above, did you previously use alcohol?
Past Medical Conditions (Check all that apply)
Family History (Check all that apply)
Started period at what age?
Date of last period (if applicable)
MM
DD
YYYY
Date of last pelvic exam (if applicable)
MM
DD
YYYY
Results of last pap (if applicable)
Are you sexually active?
Are you currently trying to get pregnant?
Are you currently using birth control? If so, what type?
What type of past birth control methods have you used? For how long?
Number of days in cycle (From Day 1 to Day 1)
Number of days of flow
Do you experience cramping?
Do you experience pelvic pain or bloating?
Do you experience premenstrual symptoms?
Describe any current changes in your cycle
Do you experience vaginal discharge?
Age at first pregnancy?
Number of full term pregnancies?
Number of miscarriages or abortions?
Have you had a tubal ligation?
Haveyou had a hysterectomy?
Have you had one or both ovaries removed?
Do you have fibrocystic breasts?
Did you ever have fertility treatments?
Would you like to add any more comment or explanation to any of the above?
Do you need a doctor recommendation?
Your doctor's name, phone, and/or email
*Client's Medical Release Authorization: I hereby release my Physician to furnish Becky Bell, R.Ph. any and all records pertaining to my medical history, services rendered, treatments, and labwork. I authorize Becky Bell, R.Ph. to release my personal or medical information to my Physician(s) upon request. I understand that my privacy will be protected and this information will be released to other healthcare professionals only when necessary in order to provide healthcare services to me. This authority becomes effective after completion of my initial consult with Becky Bell, R.Ph. and remains in effect until revoked by me in writing.
Client's Signature
*I have read and approve of the fee schedule listed on the link listed on the top of this page.
Clien't Signature
