Hormone Consultation

Due to the excellent response Rx Stat Pharmacy has had for Hormone Consultations, we now have to charge a $50.00 fee for the consultation. (This will be deducted from the first prescription filled with Rx Stat).

Credit-Card No.:	Rx Stat will process the credit-card in house. If Rx Stat has your credit-card number on file, please check the button below.If you do not want to input your credit-card number, please call the pharmacy staff. 1-888-648-7250. Prescriptions cannot be filled without a credit-card.
CCV No.:
Credit-Card Exp. date:	JanFebMarAprMayJunJulAugSepOctNovDec  12345678910111213141516171819202122232425262728293031
Is the credit-card no. (above) same as that on our files?	Yes No

First name:
Last name:
Email:
Street address:
City:
State:
Zip:
Primary Phone:	Area code:  Number:
Alternate Phone:	Area code:  Number:
Doctor:
Doctor's Phone:	Area code:  Number:
Date of Birth:
Height:
Weight:
Drug Allergies:
Smoke:	Yes  No
Alcohol:	Yes  No     No. of drinks per week
Caffeine Intake:	per day
Red Meat:	per week
Carbonated Drinks:	per week
How often do you engage in weight bearing physical exercise lasting at least 30 minutes?:	Seldom 1-2 times a week 3-4 times a week more than 5 times a week

Do you have a family history of any of the following? If so, please explain:
Breast/Endometrial Cancer If yes, at what age was the diagnosis
Fibrocystic Breasts If yes, at what age was the diagnosis
Blood Clots If yes, at what age was the diagnosis
Have you had a Hysterectomy	Yes  No
	If yes, was it  Full  Partial
	In what year
	Please detail, including the reason for the hysterectomy
Osteoporosis/Fractures If yes, at what age was the diagnosis
Have you had a Bone Mineral Density Scan?	Yes  No
	If yes, in what year
	Results

What medical conditions do you currently have or are being treated for?
What previous treatments have you attempted regarding hormone therapy? Please include HRT, diet, calcium, vitamins, nutraceuticals, biofeedback. Please include the Length of treatment
Did you have any success with the previous therapy?
Please list all prescription and non-prescription medications including vitamins and herbs that you are currently taking.
Do you know why you are taking HRT?
Have you had any side effects or problems that you believe may have been related to HRT.

What symptoms of perimenopause or menopause have you experienced? Please rate the following symptoms on a scale of one to five with five being the most severe.
Mood swings		Headaches		Crying easily		Swelling
Hot Flashes		Decreased libido		Depression		Fatigue
Weight gain		Muscle pain		Night sweats		Irritability
Vaginal dryness		Sleep disruption		Memory loss		Dry skin
Thinning hair		Tender/painful breasts

Are you still menstruating?	Yes  No
If no, when was the date of your last period?
Have your cycles always been regular?	Yes  No
If no, please provide details
Have you ever been pregnant?	Yes  No
If yes, how many term pregnancies?
What is your goal with Bio-Identical Hormone Replacement?
Are there any specific questions you would like addressed?
In order to give you the very best care, is there anything else we should know?
Comments

Your input will be reviewed by a Doctor of Pharmacy and a review sheet will be e-mailed back to you with our recommendations that you can take to your physician to request a prescription.