Toll Free: (800) 991-6509 | Fax: (866) 902-8341

3701 E Thousand Oaks Blvd. Thousand Oaks, CA 91362

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Female - Health History



Date

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Personal Information


Name (*)

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Age

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Height

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Weight

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Birthdate

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Street Address

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City

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State

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Zip Code

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Email (*)

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Phone Number (*)

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Occupation

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

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Your current medical conditions or diagnoses:

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Drug allergies:

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Allergies to food, pollens, environment, etc:

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

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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): Other:

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Names of ALL vitamins, supplements, non-prescription medicines, or other OTC products that you are currently using:

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

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Have you ever had a bone density scan?

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When and what's the result?

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Do you use tobacco products?

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For how long?

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Do you use alcohol products?

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How Much and How Long?

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Do you use caffeine products?

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What and How Much ?

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Do you use recreational drugs?

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What Recreational Drug and How Much?

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

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Is your drinking water from a:

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

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When was your last general medical exam:

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When was your last pelvic exam:

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Have you ever had an abnormal Pap?

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When and What Treatment

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At what age was your First Period (menarche)?

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

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Do you still have your period?

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If Yes, how many days from the start of one period to the start of the next?

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Number of days of flow:

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Amount of bleeding:

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Describe any cramping or pain you may have:

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

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Where, when, how long?

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Any current changes in your normal cycle?

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Any bleeding between periods (IMB):

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When and describe:

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What were your periods like as a teenager?

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

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How long have you had PMS symptoms?

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Starting and ending when:

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

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

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Describe any recent unusual vaginal discharge or itching:

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Treatment for any of above:

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Have you had any of the following surgeries?



Tubes tied (tubal ligation)?

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When and at what age?

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Uterus removed (hysterectomy)?

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When and why?

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Ovaries removed (oophorectomy)?

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If Yes or PART, What, When and Why?

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

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

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If Yes, at what age?

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

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Have you ever been pregnant?

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Are you trying to get pregnant?

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What was your age at your first pregnancy?

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How many times have you been pregnant (gravida)?

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How many pregnancies resulted in the birth of living children (para)?

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Were there any problems?

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Any interrupted pregnancies (miscarriages or abortions)?

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Current birth control method:

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How long:

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Any problems?

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



Oral Contraceptives (Birth Control Pills)

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Total months/years used:

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Describe any side effects to Birth Control Pills:

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Intra-Uterine Device (IUD)

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Problem?

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When was your last mammogram?

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Results:

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Do you examine your breasts monthly?

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

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

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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:

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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 flushes
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

  

 

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3701 E Thousand Oaks Blvd. Thousand Oaks, CA 91362 | Toll Free: (800) 991-6509 | Fax: (866) 902-8341

DISCLAIMER

Paseo Oaks Pharmacy is a licensed compounding pharmacy that only engages in compounding in response to a physician's prescription. A written prescription from a licensed physician is required for compounded medication. The information on the site is general in nature and is only intended for use as an educational tool. You should consult your physician or a Paseo Oaks Pharmacy pharmacist if you have any specific questions relating to the diagnosis and treatment of any health problems. Information and statements about products and health conditions have not been evaluated by the Food and Drugs Administration (FDA), nor has the FDA approved the products to diagnose, cure or prevent disease.

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