Please select the information that is appropriate.

                    First Name      Last Name      Date of Birth / /

                    Address      City      State      Zip Code

Day Phone         Other Phone      email

Doctors Name    Phone    Fax

How did you arrive at the decision to take natural hormones?  Select One Self Doctor Friend Other

Have you had a hysterectomy?   Select One yes no

Have you had your ovaries removed?   Select One yes no

Are you having regular menstrual periods?   Select One yes irregular none

Date of last menstrual period?  

Have you ever been diagnosed with any of the following conditions?

                    Uterine Cancer   Select One yes no I dont know Ovarian Cancer   Select One yes no I dont know Breast Cancer   Select One yes no I dont know

                     Heart Disease   Select One yes no I dont know      Osteoporosis   Select One yes no I dont know                PMS   Select One yes no I dont know

Are you currently taking hormones?   Select One yes no

                    If "yes" which one(s)?  

Are you currently taking any herbal medications?   Select One yes no

                    If "yes" which one(s)? 

Do you exercise on a regular basis?   Select One yes no

                                If "yes" how? 

How many milligrams of Calcium do you take daily?  

Please check off any of the following symptoms you have recently experienced:

   Hot Flashes   Depression   Hair loss   Loss of libido   Anxiety   Night sweats   Weight gain

   Painful intercourse   Mood swings   Headache   Fluid retention   Insomnia   Vaginal dryness   Memory loss

   Fuzzy thinking   Breast tenderness   Irritability   Painful joints   Bladder problems   Palpitations

One of our pharmacists will be contacting you by phone

What is the best time for the pharmacist to contact you  

Notes / Comments / Questions