2007 med history form

Please return your form to the Pharmacy when you have finished. The Pharmacists will meet with you to review your information. Thank you. 1. Patient Information: Today's Date:____________________

Name: ________________________________________________ Birth date: ______________________
Address: ______________________________________________ City: _______________ State: ______
Zip: ______________
Home / Work Phone #: ______________________________
Gender: Male _____ Female _____ Height: ____________ Weight: ____________
Would like to receive our monthly newsletter? Yes No Email Address: ________________________________________________________________________________________________ 2. Please list each doctor from whom you seek care, including address and phone number, if known.:
Doctor Name: _____________________________ Address: ______________________________ Phone: __________________
Doctor Name: _____________________________ Address: ______________________________ Phone: __________________
Doctor Name: _____________________________ Address: ______________________________ Phone: __________________
3. Over-the-counter (OTC) issues:
Please check all products that you use occasionally or regularly. Check all that apply. __ Pain reliever __ Combination product (cough+cold reliever.)(Example: Triaminic DM) __ Aspirin __ Sleep Aids (Examples: Excedrin PM, Unisom, Sominex, Nytol) __ Acetamorphin (Example: Tylenol) __ Antidiarrheals (Examples: Imodium, Pepto Bismol, Kaopectate) __ Ibuprofen (Example: Motrin IB) __ L axatives/stool softeners (Examples: Doxidan, Correctol, etc.) __ Naproxen (Example: Aleve) __ D iet aids/weight loss products (Example: Dexatrim) __ Ketoprofen (Example: Orudis KT) __ A __ Cough Suppressant (Example: Robitussin DM) __ A cid blockers (Examples: Tafamet HB, Pepcid AC, Zantac 75) __ Decongestant product (Example: Sudafed) __ O ther (Please List)_________________________________________
_________________________________________
4. Medical Conditions / Diseases. Please Check all that apply to yo u.
__ Heart Disease (example: Congestive Heart Failure) __ Lung condition (example: asthma, emphysema, COPD) __ High Cholesterol or lipids (examples: Hyperlipidemia) __ Diabetes __ High Blood Pressure (example: Hypertension) __ Arthritis or joint problems __ Cancer __ Depression __ Ulcers (stomach, esophagus) __ Epilepsy __ Thyroid Disease __ Headaches / Migraines __ Hormonal Related issues __ Eye Disease (glaucoma, etc.) __ Blood Clotting Problems __ Other. Please List: __________________________________ Patient Name: __________________________________________________________ SS #: __________________________________ 2000 International Academy of Compounding Pharmacists. All rights reserved. 5. Family History of Diabetes: Yes No

6. Family History of Heart Disease Yes No

7. Family History of Hormonal Cancer Yes No
What type of cancer: ________________________________________ Who: ____________________________________________

8. Have you had a bone density scan? Yes No Date: ______________________________
Results: _____________________________________________________________________________________________________
Physician’s Name: _____________________________________ Date of last exam: _________________________________

9. Drug Allergies: _____________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

10. Prescription Medications: Please list all prescription medications you are currently using, Be sure to include any mail order or
physician samples.
Medication Name Dose How many times per day? Doctor
1.
__________________________________________________________________________________________________________ __________________________________________________________________________________________________________ 3. __________________________________________________________________________________________________________ 4. __________________________________________________________________________________________________________ 5.
__________________________________________________________________________________________________________
6. __________________________________________________________________________________________________________

Patient Name: __________________________________________________________ SS #: __________________________________ 2000 International Academy of Compounding Pharmacists. All rights reserved. Hormone Replacement Therapy Specific Information
1. How did you arrive at the decision to consider Prescription Natural Hormone Replacement Therapy? __ Doctor __ Self __ Friend / family member 2. Bone Size: __ Small __ Medium __ Large 3. Have you ever used oral contraceptives? __ NO __ YES 3a. If YES, any Problems? __ NO __ YES 4. How many pregnancies have you had? __________________________ 4a. How many children? ___________________________ 5. Have you had a hysterectomy? __ NO __ YES 5a. If YES, Date of surgery: ___________________ ___ Total ___ Uterus Only 6. Have you had a tubal ligation? __ NO __ YES 7. Were you prematurely gray? __ NO __ YES 8. Have you had any of the following tests performed? Check those that apply and note date of last test. Mammography __ No __ Yes Date: _________________________ Pap Smear __ No __ Yes Date: _________________________ 9. When was your last period? ____________________________ 10. How many days did it last? __________ 11. Do you have, or did you ever have Premenstrual Syndrome (PMS)? __ No __ Yes 11a. If YES, explain Symptoms: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Patient Name: __________________________________________________________ SS #: __________________________________ 2000 International Academy of Compounding Pharmacists. All rights reserved. Hormone Replacement Therapy Specific Information
12. Do you take hormones of any kind? ___________ If so, list (include birth control pills or natural hormone cream): 13. Have you tried other hormones? ____________ If so, list: Describe your periods (For example: Are your periods regular? How many days from start of one period to the start of the next one? Num-ber of days of flow? Describe your flow. Any bleeding between periods? Do you have clots? 15. Do you have a history of vaginal/bladder infections? ___________________________________________________________________ 16. Have you ever had a miscarriage(s)?_________________________________ When_________________________________ 17. Do you have trouble sleeping: ___________No ___________ Yes, please describe: how long had this been a problem?, can you go to sleep but then wake up, have mind racing at night, etc.
__________________________________________________________________ 18. Do you have PMS symptoms? ______ Yes ______ No
If yes, when do symptoms start and stop:
____________________________________________________________________________
PMS Patients please fill in this section:

PMS-A PMS-H PMS-C PMS-D
___Nervous tension ___Weight gain ___ Headache ___ Depression
___Mood swings ___Water retention ___Cravings ___Forgetfulness
___Irritability ___Breast tenderness ___Heart palpitations ___Crying
___Anxiety ___Bloating ___Fatigue ___Insomnia
2000 International Academy of Compounding Pharmacists. All rights reserved. DIET / LIFESTYLE
1. Dietary Restrictions:
_________________________________________________________________________
_________________________________________________________________________

Describe typical meal choices:
Breakfast:__________________________________________________________________________________ Lunch:_____________________________________________________________________________________ Dinner: ____________________________________________________________________________________ 2. Do you get regular exercise? Yes______ No______ If yes, please describe:
_______________________________________________________________________________________
_______________________________________________________________________________________
3. Stress Level: High ___________ Moderate: ___________ None: ____________

STRESS MANAGEMENT: Do you practice any stress management techniques? _____ YES _____NO
If YES, describe what you do and how often?
4. Do you experience low blood sugar symptoms or hypoglycemia? ______________________ For example:
5. Do you get shakie, dizzy, or irritable if you do not eat or eat sugar? _______Yes _______No
Current Supplements: (include milligrams/dosages): ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 6. Number of regular bowel movements on a daily basis? _______________________________________________ Lifestyle Information:

3. General Health: Good Fair Poor
4. Energy Level: High Fairly High Low
5. Blood Pressure: __________________________________
6. Cholesterol Level: (If Known): Total: _________________ Date: _________________
HDL: ________ LDL: _________ Triglycerides: __________________
IMPAIRMENTS: Check if you have any of the following:
____ Physical Impairment ____ Visual Impairment ____Hearing Impairment
EXERCISE: Do you exercise regularly? ______ YES ______ NO
2000 International Academy of Compounding Pharmacists. All rights reserved. 7. Please list major concerns and the goals that you would like to achieve with natural hormone replacement therapy and/or hormonal balancing: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Impression / Notes (for office use): ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 2000 International Academy of Compounding Pharmacists. All rights reserved. Please read the following list of symptoms and rate their severity on the corresponding lines using the following keys: Moderate
Today Follow-up 1 Follow-up 2 Follow-up 3
Symptoms of Low Estrogen
Dry Skin ________ _________ _________ ________
Heart Palpitations ________ _________ _________ ________
Hot Flashes ________ _________ _________ ________
Inability to reach climax ________ _________ _________ ________
Night sweats ________ _________ _________ ________
Painful intercourse ________ _________ _________ ________
Sleep disturbances ________ _________ _________ ________
Urinary incontinence ________ _________ _________ ________
Urinary tract infections (UTI’s) ________ _________ _________ ________
Yeast infections ________ _________ _________ ________
Symptoms of Low Progesterone

Anxiety ________ _________ _________ ________
Cramping ________ _________ _________ ________
Insomnia ________ _________ _________ ________
Irregular menses ________ _________ _________ ________
Joint Pain ________ _________ _________ ________
Mood swings ________ _________ _________ ________
PMS ________ _________ _________ ________
Swollen breasts ________ _________ _________ ________
Water retention ________ _________ _________ ________
Weight gain ________ _________ _________ ________
Symptoms of Low Testosterone

Blunted motivation ________ _________ _________ ________
Diminished feeling of well-being ________ _________ _________ ________
Fatigue, prolonged ________ _________ _________ ________
General aches and pains ________ _________ _________ ________
Muscle weakness ________ _________ _________ ________
Symptoms of Both Low Estrogen
and Testosterone

Thinning skin ________ _________ _________ ________
Vaginal dryness ________ _________ _________ ________
Symptoms of Low Estrogen,
Progesterone, and/or Testosterone

Depression ________ _________ _________ ________
Fuzzy thinking ________ _________ _________ ________
Hair loss ________ _________ _________ ________
Headaches ________ _________ _________ ________
Irritability ________ _________ _________ ________
Low sex drive ________ _________ _________ ________
Memory lapses ________ _________ _________ ________
117 West Church Street ? Nashville, NC 27856 Pharmacy Record Release Authorization
I, undersigned patient, authorize my pharmacist to release my personal medication and/or other medical information to my health care provider upon request or as deemed necessary. I understand that employees of Ward Drug Company Pharmacy will protect my privacy and this information will be released to other health care professionals only when it is necessary in order to provide health care services to me. This authority shall continue until revoked by me in writing. Patient Name: ______________________________________________________________ Address: __________________________________________________________________ City, State, Zip: ____________________________________________________________ Phone: ________________________________________________ Signature: ________________________________________________________________ Date: ________________________________________ Patient Name: ______________________________ SS#: __________________

Source: http://www.warddrug.com/_pdfs/2008medicalhistoryform.pdf