Women - Custom Compounding Center

Today's Date*

Name

First Last

Address*

Street Address City State ZIP Code

Phone*

Email*

Date of Birth*

Age*

Height*

Weight*

Do you use tobacco?*

How often do you use tobacco?*

Do you use alcohol?*

How often do you use alcohol?*

Do you use caffeine? **

How often do you use caffeine?*

Doctor's Name:*

Doctor's Address*

Street Address City State ZIP Code

Do you have any known allergies?*

Describe your allergic reactions and when they occured?*

Are you currently taking any over the counter medications?*

Are you currently taking any nutritional or natural supplements?*

Please list all OTC/nutritional supplements and dosages:*

Please list all prescribed medications name, strength, date started and how often used:*

Please list any personal medical history conditions and/or diseases:*

Please provide any hormones previously taken:*

Between what date's did you take these hormones?*

What was the reason for taking these hormones?*

Have you ever used oral contraceptives?*

If you had any problems with oral contraceptives please describe:

How many pregnancies have you had?*

Any interrupted pregnancies?*

Have you had a hysterectomy?*

Hysterectomy (date)*

Ovaries removed:*

Have you had a tubal ligation?*

Tubal ligation (date)*

Date of last mammography?*

Date of last PAP smear?*

Since beginning your periods, have you had what you would consider abnormal cycles?

Please explain your abnormal cycles:*

When was your last period?*

How many days did it last?*

Do you have, or did you have Premenstral Syndrome (PMS)?

Please explain your Premenstral Syndrome (PMS):*

How would you prefer to take your customized hormone replacement therapy?*

How did you decide to consider customized hormone replacement therapy?

What are your goals for taking customized hormone replacement therapy?*

Do you have any questions about customized hormone replacement therapy?*

Choose all that Apply to your family history:*

Uterine Cancer
Ovarian Cancer
Fibrocystic Breast
Breast cancer
Heart Disease
Osteoporosis

What family member?

Please list all symptoms (hot flashes, night sweats, fatigue, etc) you are currently having:

How Did You Hear About Us?*

Provider Referral
Website
Friend
Other

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