Bobwoodrph.com

Bob Wood, RPh and IHC Consultant
7870 Olentangy River Road, Suite 202
Columbus, OH 43235
Ph: 614-847-0109
Fax: 614-847-0960
www.IntegrativeHormoneConsulting.com
Confidential Female Medical History Form
Name: ______________________________________________ Date of Birth: _________________ Age: ____________ Address: ______________________________________________________________ City: _______________________________ State: _________ Zip: ________________ Phone (Home): _____________________ Work: ____________________ Email: ________________________________ Best Time to Call: ___________________________________________________________________________________ Occupation: ________________________ Ful Time: ___ Part Time: ___ Retired: ___ Unemployed: ___ Other: ___ Living Situation: Spouse: ___ Alone: ___ Partner: ___ Friend(s): ___ Parents: ___ Children: ___ Other: ___ Marriage Status: Married: ___ Single: ___ Divorced: ___ Widowed: ___ Height: __________ Weight: __________ BMI: _________ Pets: ______________________________________________________________________________________________ How did you arrive at the decision to consider Bioidentical Hormone Replacement Therapy? Doctor: __________ Self: __________ Family Member/ Friend: __________ Other: __________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Please describe the al ergic reaction you experienced when it occurred: __________________________________________________________________________________________________ __________________________________________________________________________________________________ Medical Conditions/ Diseases Past & Present: Please check all that apply to you. _____ Heart Disease (ex. Congestive Heart Failure) _____ High Blood Pressure (ex. Hypertension) _____ Lung Condition (ex. Asthma, Emphysema, COPD) _____ High Cholesterol or Lipids (ex. Hyperlipidemia) If other, please list: __________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Over the Counter (OTC) Issues: Please check all products that you use occasionally or regularly. ________ Combination cough +cold reliever (ex. Triaminic®) ________ Sleep aids (ex. Excedrin PM®, Unisom®, Sominex®) ________ Antidiarrheals (ex. Imodium®, PeptoBismol®, ________ Laxatives/ Stool Softeners (ex. Doxidan®, Correctol®) ________ Diet Aids/ Weight loss products (ex. Dexatrim®) ________ Antacids (ex. Maalox®, Mylanta®) ________ Cough Suppressant (ex. Robitussin DM®) ________ Acid Blockers (ex. Tagamet HB®, Pepcid AC®, Zantac ________ Antihistamine product (ex. Chlor- Trimeton®) ________ Decongestant product (ex. Sudafed®) If others, please list: ____________________________________________________________________________________ Nutritional/ Natural Supplements: Please identify and list the products you are using. ________ Vitamins (ex. Multiple or single vitamins such as B complex, E, C, Beta Carotene) ________ Minerals (ex. Calcium, magnesium, chromium, colloidal minerals, various single minerals) ________ Herbs (ex. Ginseng, Gingko Biloba, Echinacea, other herbal medicinal tests, tinctures, remedies, etc.) ________ Enzymes (ex. Digestive formulas, papaya, bromelain, CoEnzyme Q10, etc.) ________ Nutritional/ protein supplements (ex. Shark cartilage, protein powders, amino acids, fish oil, etc.) Have you had any of the fol owing tests performed? Please check those that apply and note the date of the last test. No: ___________ Yes: ___________ Date: _______________ Results: _____________ No: ___________ Yes: ___________ Date: _______________ Results: _____________ No: ___________ Yes: ___________ Date: _______________ Results: _____________ Do you use tobacco? No: ___________ Yes: ___________ How often/ How much? ______________________ No: ___________ Yes: ___________ How often/ How much? ______________________ Do you use caffeine? No: ___________ Yes: ___________ How often/ How much? ______________________ Do you get routine physical exercise? No: ___________ Yes: ___________ What type? ___________________ Breakfast: _________________________________________________________________________ Lunch: ____________________________________________________________________________ Dinner: ___________________________________________________________________________ Do you have a family history of any of the following? Family Member(s): ______________________________________________ Family Member(s): ______________________________________________ Family Member(s): ______________________________________________ Family Member(s): ______________________________________________ Family Member(s): ______________________________________________ Family Member(s): ______________________________________________ Gynecological History
Age at first period: _______ Date of last period: ______________ Date of last pelvic exam: ______________ Date of last PAP smear: ______________ Results: ____________________ Have you ever had an abnormal PAP? _______________ Treatment: ________________________________________ Are you sexual y active? ______________ Are you trying to get pregnant? ___________________________ Current Birth Control Method: ___________________________________ How long? ___________________________ Any Problem with Birth Control Method: ___________________________ How long? ___________________________ Past birth control and any related problems: ______________________________________________________________ How many days from start of one period to the start of next: ________________________________________________ Number of days flow: ________ Amount of bleeding: __________________ Amount of cramps: _________________ Premenstrual symptoms: _____________________________________________________________________________ Starting and ending when: ____________________________________________________________________________ Any current changes in your normal cycle: _______________________________________________________________ Are you bleeding between periods? ______________________________ When: _______________________________ Any pelvic pain, pressure or ful ness? _____________________ Describe: _____________________________________ Any unusual vaginal discharge or itching? _________________ Describe: _____________________________________ Treatment: ________________________________________________________________________________________ Age at first pregnancy: ___________ How many ful term pregnancies? _____________________________________ Problems with pregnancies: ___________________________________________________________________________ __________________________________________________________________________________________________ Any interrupted pregnancies (miscarriages or abortions)? ___________________________________________________ Have you had a tubal ligation? ______________________ When: __________________________________________ Have you had any part or a whole ovary removed? ___________________ When: _____________________________ Have you had a hysterectomy? ______________________ When: __________________________________________ Do your ovaries remain? ______________________________________________________________________________ Have you experienced any of the following symptoms recently? Please circle the number that best describes your experiences with 1 being Extremely Mild and 4 being Extremely Severe. Hormone Replacement Therapy Patient Information Sheet
Thyroid Deficiency

Source: http://www.bobwoodrph.com/IHC_Medical_History_Women.pdf