Women's Consultation Form

Date Date / MM / DD YYYY
Personal Information
Name Name First Last
Age
Height
Weight
Birthdate Birthdate / MM / DD YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Fax Fax - ### - ### ####
Occupation
What is your greatest need or problem? (List the most important; then list other issues in order of importance):
Your current medical conditions or diagnoses:
Drug allergies:
Allergies to food, pollens, environment, etc:
Names of ALL prescription medications, taken in last 6 months. Include strength and how you take them:
Indicate any herbal products you have taken: (Evening Primrose Oil (EPO), Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc): Other:
Names of ALL Vitamins, Supplements, Non-prescription medicines, or other OTC products that you are currently using:
If you are you currently taking medication for a thyroid condition, which one and dose?
Have you ever had a bone density scan?
When?
Results
Do you use tobacco products?
What?
For how long?
Do you use alcohol products?
What?
How much?
For how long?
Do you use caffeine products?
What?
How much?
Do you use recreational drugs?
What?
How much?
How much water do you drink in one day (24 hr)?
Is your drinking water from a:
Dietary Restrictions (such as salt, carbohydrates, milk products, red meat, etc):
When was your last general medical exam: When was your last general medical exam: / MM / DD YYYY
When was your last pelvic exam: When was your last pelvic exam: / MM / DD YYYY
Have you ever had an abnormal Pap?
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?
If 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?
Where, when, how long?
Any current changes in your normal cycle?
Any bleeding between periods (IMB):
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)?
When?
At what age?
Uterus removed (hysterectomy)?
When?
Why?
Ovaries removed (oophorectomy)?
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?
If Yes, at what age?
If at age 40 years or earlier, was Premature Ovarian Failure, diagnosed?
Have you ever been pregnant?
Are you trying to get pregnant?
What was your age at your first pregnancy?
What was your age at your first pregnancy?
How many times have you been pregnant (gravida)?
How many times have you been pregnant (gravida)?
How many pregnancies resulted in the birth of living children (para)?
How many pregnancies resulted in the birth of living children (para)?
Were there any problems?
Were there any problems?
Any interrupted pregnancies (miscarriages or abortions)?
Any interrupted pregnancies (miscarriages or abortions)?
Current birth control method:
Current birth control method:
How long:
How long:
Any problems?
Any problems?
Have you ever used any of the following birth control methods:
Oral Contraceptives (Birth Control Pills)
Total months/years used:
Total months/years used:
Describe any side effects to Birth Control Pills:
Describe any side effects to Birth Control Pills:
Intra-Uterine Device (IUD)
Problems?
Problems?
When was your last mammogram?
When was your last mammogram?
Results:
Results:
Do you examine your breasts monthly?
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.
	0	1	2	3
Hot flushes	Hot flushes0	Hot flushes1	Hot flushes2	Hot flushes3
Night sweats	Night sweats0	Night sweats1	Night sweats2	Night sweats3
Light-headed feelings/dizziness	Light-headed feelings/dizziness0	Light-headed feelings/dizziness1	Light-headed feelings/dizziness2	Light-headed feelings/dizziness3
Headaches	Headaches0	Headaches1	Headaches2	Headaches3
Sleep disorders/Sleeplessness	Sleep disorders/Sleeplessness0	Sleep disorders/Sleeplessness1	Sleep disorders/Sleeplessness2	Sleep disorders/Sleeplessness3
Unusual tiredness/Fatigue	Unusual tiredness/Fatigue0	Unusual tiredness/Fatigue1	Unusual tiredness/Fatigue2	Unusual tiredness/Fatigue3
Irritability	Irritability0	Irritability1	Irritability2	Irritability3
Depression	Depression0	Depression1	Depression2	Depression3
Anxiety/Tension/Nervousness	Anxiety/Tension/Nervousness0	Anxiety/Tension/Nervousness1	Anxiety/Tension/Nervousness2	Anxiety/Tension/Nervousness3
Mood swings/Mood changes	Mood swings/Mood changes0	Mood swings/Mood changes1	Mood swings/Mood changes2	Mood swings/Mood changes3
Confusion/Difficulty concentrating	Confusion/Difficulty concentrating0	Confusion/Difficulty concentrating1	Confusion/Difficulty concentrating2	Confusion/Difficulty concentrating3
Forgetfulness/Short-term memory loss	Forgetfulness/Short-term memory loss0	Forgetfulness/Short-term memory loss1	Forgetfulness/Short-term memory loss2	Forgetfulness/Short-term memory loss3
Angry outbursts/Arguments/ Violent tendencies	Angry outbursts/Arguments/ Violent tendencies0	Angry outbursts/Arguments/ Violent tendencies1	Angry outbursts/Arguments/ Violent tendencies2	Angry outbursts/Arguments/ Violent tendencies3
Crying easily	Crying easily0	Crying easily1	Crying easily2	Crying easily3
Backache	Backache0	Backache1	Backache2	Backache3
Joint pains	Joint pains0	Joint pains1	Joint pains2	Joint pains3
Muscle pains	Muscle pains0	Muscle pains1	Muscle pains2	Muscle pains3
Muscle cramps/spasms	Muscle cramps/spasms0	Muscle cramps/spasms1	Muscle cramps/spasms2	Muscle cramps/spasms3
Problems with wound healing time	Problems with wound healing time0	Problems with wound healing time1	Problems with wound healing time2	Problems with wound healing time3
Acne/Pimples/Skin flushing	Acne/Pimples/Skin flushing0	Acne/Pimples/Skin flushing1	Acne/Pimples/Skin flushing2	Acne/Pimples/Skin flushing3
New facial hair	New facial hair0	New facial hair1	New facial hair2	New facial hair3
Dry skin/Dry hair	Dry skin/Dry hair0	Dry skin/Dry hair1	Dry skin/Dry hair2	Dry skin/Dry hair3
Crawling feeling under skin	Crawling feeling under skin0	Crawling feeling under skin1	Crawling feeling under skin2	Crawling feeling under skin3
Frequent Urinary Tract Infection (UTI)	Frequent Urinary Tract Infection (UTI)0	Frequent Urinary Tract Infection (UTI)1	Frequent Urinary Tract Infection (UTI)2	Frequent Urinary Tract Infection (UTI)3
Urinary frequency	Urinary frequency0	Urinary frequency1	Urinary frequency2	Urinary frequency3
Vaginal dryness	Vaginal dryness0	Vaginal dryness1	Vaginal dryness2	Vaginal dryness3
Abnormal bleeding	Abnormal bleeding0	Abnormal bleeding1	Abnormal bleeding2	Abnormal bleeding3
Pelvic pain, pressure, fullness, or bloating	Pelvic pain, pressure, fullness, or bloating0	Pelvic pain, pressure, fullness, or bloating1	Pelvic pain, pressure, fullness, or bloating2	Pelvic pain, pressure, fullness, or bloating3
Uncomfortable intercourse	Uncomfortable intercourse0	Uncomfortable intercourse1	Uncomfortable intercourse2	Uncomfortable intercourse3
Loss of sexual feeling/desire	Loss of sexual feeling/desire0	Loss of sexual feeling/desire1	Loss of sexual feeling/desire2	Loss of sexual feeling/desire3
Loss of arousability & capacity for orgasm	Loss of arousability & capacity for orgasm0	Loss of arousability & capacity for orgasm1	Loss of arousability & capacity for orgasm2	Loss of arousability & capacity for orgasm3
Loss of vitality	Loss of vitality0	Loss of vitality1	Loss of vitality2	Loss of vitality3
Nipple sensitivity	Nipple sensitivity0	Nipple sensitivity1	Nipple sensitivity2	Nipple sensitivity3
Discharge or leaking from nipples	Discharge or leaking from nipples0	Discharge or leaking from nipples1	Discharge or leaking from nipples2	Discharge or leaking from nipples3
Breast tenderness	Breast tenderness0	Breast tenderness1	Breast tenderness2	Breast tenderness3
Loss of pubic hair	Loss of pubic hair0	Loss of pubic hair1	Loss of pubic hair2	Loss of pubic hair3
Swelling of hands, ankles, or breasts	Swelling of hands, ankles, or breasts0	Swelling of hands, ankles, or breasts1	Swelling of hands, ankles, or breasts2	Swelling of hands, ankles, or breasts3
Heart palpitations	Heart palpitations0	Heart palpitations1	Heart palpitations2	Heart palpitations3
Shortness of breath	Shortness of breath0	Shortness of breath1	Shortness of breath2	Shortness of breath3
Food /sweets /salt cravings	Food /sweets /salt cravings0	Food /sweets /salt cravings1	Food /sweets /salt cravings2	Food /sweets /salt cravings3
Increased appetite/weight gain	Increased appetite/weight gain0	Increased appetite/weight gain1	Increased appetite/weight gain2	Increased appetite/weight gain3
Increased appetite/weight gain	Increased appetite/weight gain0	Increased appetite/weight gain1	Increased appetite/weight gain2	Increased appetite/weight gain3
Visual disturbance or decreased vision	Visual disturbance or decreased vision0	Visual disturbance or decreased vision1	Visual disturbance or decreased vision2	Visual disturbance or decreased vision3
Difficulty hearing	Difficulty hearing0	Difficulty hearing1	Difficulty hearing2	Difficulty hearing3
Diminished sense of taste	Diminished sense of taste0	Diminished sense of taste1	Diminished sense of taste2	Diminished sense of taste3
Diminished sense of smell	Diminished sense of smell0	Diminished sense of smell1	Diminished sense of smell2	Diminished sense of smell3

I acknowledge that I am submitting my health information to initiate a consultation with the pharmacist. I understand that although the most secure transmission methods are used, security cannot be 100% guaranteed.

I acknowledge that I am submitting my health information to initiate a consultation with the pharmacist. I understand that although the most secure transmission methods are used, security cannot be 100% guaranteed. Yes

Women's Consultation Form

Women's Consultation Form

Personal Information

Have you had any of the following surgeries?

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

Symptoms