BHRT Analysis

General Information

Current Condition and Medical History

What is your Greatest Need or Problem?
Please list all issues in order of importance

Please list any current Medical Conditions or Diagnoses:

Please list any Drug Allergies:

Please list any Other Allergies:  (i.e. - food, pollens, environment, etc.)

Medication, Substance Use, and Dietary Consumption

Prescription Medications:
Please list all prescription medications taken in the last 6 months, their strength, and how you take them:

Herbal Products:
Please list any herbal products you have recently taken (i.e. - Evening Primrose Oil [EPO], Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc.)

Additional Vitamins, Supplements, or Medications:
Please list all other vitamins, supplements, non-prescription medicines, or other OTC products you are currently using

Tobacco Use:
Do you use tobacco products?  Yes  No

Alcohol Use:
Do you use alcohol products?  Yes  No

Caffeine Use:
Do you use caffeine products?  Yes  No

Recreational Drug Use:
Do you use recreational drugs?  Yes  No

Water Intake:
How much water do you drink in one day (24 hour period)?

Water Source:
Where does your drinking water normally come from?
Home Well     City Water     Distilled Water     Bottled Water     Water Purifier

Dietary Restrictions:
Please list any dietary restrictions you may have (i.e. - salt, carbohydrates, milk products, red meat, etc.)

Exams, Procedures, and Tests

Bone Density Scan:
Have you ever had a bone density scan?  Yes  No

When was your last General Medical Exam: 

When was your last Pelvic Exam: 

Gynecological and Menstruation History

Have you ever had an Abnormal Pap?  Yes  No

At what age was your First Period (menarche): 

When was your Most Recent or Last Period (LMP): 

Your Period:
Do you Still Have your Period?  Yes  No

Describe any Cramping or Pain you may have:

Do you have Pain at any Other Time in your Cycle?  Yes  No

Are there any Current Changes in your Normal Cycle:  (if so, please describe)

Do you have any Bleeding between Periods (IMB):  (if so, please describe)

What were your Periods like as a Teenager:

Have you ever had Premenstrual Symptoms (PMS): (if so, please describe)

How long have you had PMS Symptoms? When do they generally start and end?

Have your Periods ever been Difficult, Irregular, or Abnormal in any way: (if so, please describe)

Are you currently having an Pelvic Pain, Pressure, or Fullness: (if so, please describe)

Have you had any recent unusual Vaginal Discharge or Itching: (if so, please describe)

Have you had Treatment for any of the conditions listed above: (if so, please describe)

Surgeries

Have you ever had your Tubes Tied (tubal ligation)?  Yes  No

Have you ever had your Uterus Removed (hysterectomy)?  Yes  No

Have you ever had your Ovaries Removed (oophorectomy)?  Yes  No

Were there any problems associated with the surgery or removal of any organs:

Menopause

Has your doctor diagnosed menopause, or told you that you are in menopause?  Yes  No

Were you ever diagnosed with Premature Ovarian Failure at or before the age of 40?  Yes  No

Pregnancy and Child Birth

Have you ever been Pregnant?  Yes  No

Are you trying to get Pregnant?  Yes  No

What was your Age at your First Pregnancy:

How Many Times have you been Pregnant (gravida):

How Many Pregnancies resulted in the Birth of Living Children (para):

Have you had any Problems During Pregnancy: (if so, please describe)

Have you had any Interrupted Pregnancies (Miscarriages or Abortions): (if so, please describe)

Birth Control and Contraceptives

Are you Currently Using Birth Control?  Yes  No

Have you ever used Oral Contraceptives (Birth Control Pills)?  Yes  No

Have you ever used an Intra-Uterine Device (IUD)?  Yes  No

Breast Exams and Health

When was your last Mammogram: 

What were the Results of that Mammogram: 

Do you Examine your Breasts Monthly?  Yes  No

Have you ever experienced Breast Pain, Discomfort, Nipple Discharge, or Swelling other than when Pregnant: (if so, please describe)

Have you ever been Diagnosed with Lumps, Fibroids, Breast Cancer, or Similar Breast Conditions: (if so, please describe)

If your doctor has recently ordered lab tests or diagnostic procedures for you, please give details, including whether the test or procedure was performed, and the results:

Symptoms

Check the appropriate box for each symptom that best describes how you have been feeling for the past 3 weeks.

None:  symptom not present
Mild:  present but not distressing
Moderate:  distressing, but not interfering with daily life
Severe:  very distressing, interferes with daily life

If you wish to add comments or details, please send by separate email to our pharmacy, indicating your first and last name in the email. Thank you.