Female Hormone Consultation Form

Name: NextGenRx Compounding Pharmacy
Price range: $

After completing this Female Hormone Consultation Form, our pharmacy team will reach you via phone to confirm what date your phone consultation will take place. We look forward to helping you!

"*" indicates required fields

Today's Date*

Personal Information

Name*

Are you a vitality program member?*

Yes

Date of Birth*

Age*

Height*

Weight*

Address*

Email*

Phone*

Work Phone

Occupation

Primary Physician*

Primary Physician Phone*

Secondary Physician

Secondary Physician Phone

What is your greatest need or problem? (List the most important; then list other issues in order of importance):*

N/A

Other

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Your current medical conditions or diagnoses:*

N/A

Other

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Drug allergies:*

N/A

Other

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Allergies to food, pollens, environment, etc:*

N/A

Other

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Names of ALL prescription medications, taken in last 6 months. Include strength and how you take them:*

N/A

Other

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Indicate any herbal products you have taken: (Evening Primrose Oil (EPO), Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc):*

N/A

Other

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Names of ALL Vitamins, Supplements, Non-prescription medicines, or other OTC products that you are currently using:*

N/A

Other

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If you are you currently taking medication for a thyroid condition, which one and dose?*

N/A

Other

Please enter information here

Have you ever had a bone density scan?*

Yes

Date

Results

Do you use tobacco products?*

Yes

What?

For how long?

Do you use alcohol products?*

Yes

What?

How much?

For how long?

Do you use caffeine products?*

Yes

What?

How much?

Do you use recreational drugs?*

Yes

What?

How much?

How much water do you drink in one day (24 hr)?*

Glasses / Ounces

Glasses

Ounces

Is your drinking water from*

City Water

Distilled Water

Bottled Water

Water Purifier

Dietary Restrictions (such as salt, carbohydrates, milk products, red meat, etc):*

N/A

Other

Please enter information here

Family History: List Important Diseases

Mother

Mother Living / Deceased

Living

Deceased

Father

Father Living / Deceased

Living

Deceased

Brothers

Brothers Living / Deceased

Living

Deceased

Sisters

Sisters Living / Deceased

Living

Deceased

Aunts

Aunts Living / Deceased

Living

Deceased

Uncles

Uncles Living / Deceased

Living

Deceased

Paternal Grandma

Paternal Grandma Living / Deceased

Living

Deceased

Paternal Grandpa

Paternal Grandpa Living / Deceased

Living

Deceased

Maternal Grandma

Maternal Grandma Living / Deceased

Living

Deceased

Maternal Grandma

Maternal Grandma Living / Deceased

Living

Deceased

When was your last general medical exam:*

When was your last pelvic exam:

Have you ever had an abnormal Pap?*

Yes

When?

Treatment

At what age was your First Period (menarche)?*

When was your most recent or last period (LMP):*

Do you still have your period?*

Yes

How many days from the start of one period to the start of the next?*

Number of days of flow:*

Amount of bleeding:

Describe any cramping or pain you may have:*

Do you have pain at any other time in your cycle?*

Yes

Where, when, how long?

Any current changes in your normal cycle?*

Any bleeding between periods (IMB):*

Yes

When and describe:

What were your periods like as a teenager?*

Have you have ever had Premenstrual Symptoms (PMS), please describe:*

How long have you had PMS symptoms?*

Starting and ending when:

If your periods have ever been difficult, irregular, or abnormal in any way, please describe:

If you are you currently having any pelvic pain, pressure, or fullness, describe:

Describe any recent unusual vaginal discharge or itching:

Treatment for any of above:

Have you had any of the following surgeries?

Tubes tied (tubal ligation)?*

Yes

When?

At what age?

Uterus removed (hysterectomy)?*

Yes

When?

Why?

Ovaries removed (oophorectomy)?*

Yes

Part

If Yes or PART, What?

When?

Why?

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

Has your doctor diagnosed menopause, or told you that you are in menopause?*

Yes

If Yes, at what age?

If at age 40 years or earlier, was Premature Ovarian Failure, diagnosed?

Yes

Have you ever been pregnant?*

Yes

Are you trying to get pregnant?*

Yes

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)?

Were there any problems?

Any interrupted pregnancies (miscarriages or abortions)?

Current birth control method:

How long:

Any problems?

Have you ever used any of the following birth control methods:

Oral Contraceptives (Birth Control Pills)*

Yes

Total months/years used:

Describe any side effects to Birth Control Pills:

Intra-Uterine Device (IUD)*

Yes

Problems?

When was your last mammogram?

Results:

Do you examine your breasts monthly?*

Yes

Have you ever experienced breast pain, discomfort, nipple discharge, or swelling other than when pregnant? Give details:

Have you ever been diagnosed with lumps, fibroids, breast cancer, or similar breast conditions?

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 A BOX FOR EACH SYMPTOM which best describes how you have been feeling for the past 3 weeks.

0 = None (symptom not present)
1 = Mild (present but not distressing)
2 = Moderate (distressing, but not interfering with daily life)
3 = 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.

Hot flashes*

Night sweats*

Light-headed feelings/dizziness*

Headaches*

Sleep disorders/Sleeplessness*

Unusual tiredness/Fatigue*

Irritability*

Depression*

Anxiety/Tension/Nervousness*

Mood swings/Mood changes*

Confusion/Difficulty concentrating*

Forgetfulness/Short-term memory loss*

Angry outbursts/Arguments/Violent tendencies*

Crying easily*

Backache*

Joint pains*

Muscle pains*

Muscle cramps/spasms*

Problems with wound healing time*

Acne/Pimples/Skin flushing*

New facial hair*

Dry skin/Dry hair*

Crawling feeling under skin*

Frequent Urinary Tract Infection (UTI)*

Urinary frequency*

Vaginal dryness*

Abnormal bleeding*

Pelvic pain, pressure, fullness, or bloating*

Uncomfortable intercourse*

Loss of sexual feeling/desire*

Loss of arousability & capacity for orgasm*

Loss of vitality*

Nipple sensitivity*

Discharge or leaking from nipples*

Breast tenderness*

Loss of pubic hair*

Swelling of hands, ankles, or breasts*

Heart palpitations*

Shortness of breath*

Food /sweets /salt cravings*

Increased appetite/weight gain*

Visual disturbance or decreased vision*

Difficulty hearing*

Diminished sense of taste*

Diminished sense of smell*

Schedule Consultation

Please select 3 times that work best for a phone consultation with one of our pharmacists. Our times offered are Monday - Friday with time blocks from 9:00am-12:00pm, 12:00pm-3:00pm or 3:00pm-6:00pm. Consults typically last between 30 minutes and one hour. We will check availability and get back with you with a specific time.

Date*

Time Block*

Date*

Time Block*

Date*

Time Block*

Phone

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