Natural Hormone Replacement Questionnaire

If you are interested in having Yakim's Compounding Pharmacy evaluate your hormone needs and contact your physcian or prescriber, please fill in the following questionnaire. If you have difficulty, please, don't hesitate to call us.
Natural Hormone Replacement Questionnaire

* Name
* Street Address
Street Address (page two)
* City
* State
* Zip Code
* Phone Number
* Email Address
* Date of Birth
* Weight
* Height
* Waist Measurement
* Hip Measurement
* Body Frame
* List All Current Medications, Hormones and Supplements
List Allegies to Food or Medications
List all Prior gynecological surgeries, including date
List all Current and Previous gynecological diagnosis
List all Current and Previous Cardiac Complications
List all Other Previous and Current Medical Conditions
* Sleep Disturbances
* Hot Flashes
* Skin Changes
* Changes in Mental Function
* Vaginal Changes
* Breast Changes
* Changes in Hair
* Changes in bladder/bowel function
* Weight fluctuations
* Sexual Dysfunction
* Do you use caffeine products	Yes No
How much caffeine
* Do You Use Alcohol	Yes No
How Much Alcohol
* Do You Use Tobacco Products	Yes No
How Much Tobacco
* Do You Excericse	Yes No
How Much Excercise
* Number or Pregnancies
* Number of Births
* Age of First Period
Age of First Pregnancy
* History of Heart Disease
* History of Fibroids
* History of Breast Cander
* History of Osteoporosis
* Physician's Name
* Physician's Phone Number
* What is Your Worst Symptom
Goals of Therapy
Comments
* How were you referred to us
* When the pharmacist has an option, do you prefer oral or transdermal medication? Sometimes the condition dictates the choice but often times, there is a choice.
* I have read the permission statement below	Yes No

By submitting this information to Yakim's Compounding Pharmacy, you are authorizing Yakim's Compounding Pharmacy to discuss this with appropriate healthcare providers including your provider. After receiving your questionnaire, Yakim's Compounding Pharmacy will contact your presriber with our written recommendation. Yakim's Compounding Pharmacy will then contact you, via telephone, after receiving a response from your prescriber.