Microsoft word - medical history form revised.doc

10. Hormone Replacement Medication History
Please identify all the products you have used
How Often?
(e.g. # times
Pharmacist’s Comments
Estrogens (e.g. Premarin®, C.E.S. ®,
Topical Estrogens (e.g. Estrogel®,
Vagifem, Estraderm®, Vivelle, Climara®, Estradot®, Premarin® Vag Cream, Tri-est) Progestins (e.g. Provera®, MPA,
Progesterones (e.g. Prometrium®,
Combination Products (e.g. FemHRTTM,
Selective Estrogen Receptor Modulators
Other Hormonal Products (e.g. Estring®,
Mirena®, Plan BTM, Cyclomen®, Pregnyl®, Testosterone (e.g. Climacteron®, Andriol®)
Hormone Replacement Therapy Specific Information
1. How did you arrive at the decision to consider Prescription Bio-identical Hormone Replacement Androgenic (i.e.: boyish build, small breasts, narrow hips) Estrogenic (i.e.: girlish build, large breasts and hips) 4. Have you ever used oral contraceptives? NO YES 4a. If YES, any problems? NO YES Please describe: ______________________________________________________________________ ____________________________________________________________________________________ 5a. Have you had trouble becoming pregnant or maintaining a pregnancy? NO YES 7. Have you had a tubal ligation? NO YES 8. Do you have a family history of any of the following? Check all that apply: 10. Have you had any of the following tests performed? Check those that apply and note date of last test. 11. Since you first began having periods, have you ever had what YOU would consider to be abnormal cycles? NO YES 11a. If YES, please explain (such as age when this occurred, symptoms…): 13. Do you have, or did you ever have Premenstrual Syndrome (PMS)? NO YES Hormone Replacement Therapy Patient Information Sheet

Have you experienced any of the following symptoms recently? Please circle the number that best describes your
experiences, with one being Extremely Mild and ten being Extremely Severe.
Sleep Disruptions
Vaginal Dryness
Breast Tenderness
Hot Flashes
Mood Swings
Loss of Recent Memory
Weight Gain
Decreased Sex Drive
Fluid Retention
Night Sweats
Hair loss
Harder to Reach Climax 0 1 2 3 4 5 6 7 8 9 10
Bladder Symptoms
Other: _______________ 0 1 2 3 4 5 6 7 8 9 10
Question Documentation Form
Please write down any questions you may have about Prescription Bio-identical Hormone Replacement Therapy, other medications, or any other questions that come up as you read through the materials you have received. Bring this question sheet with you to your consultation so you can discuss this information with your pharmacist. Thank you. 1. 2. 3. 4. 5.


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Microsoft word - drugcalcpractice.doc

DOSAGE CALCULATIONS: ADDITIONAL PRACTICE QUESTIONS DRUG CALCULATIONS Using the following Basic Formula can help to simplify drug calculations: D x V = Dosage Required H D = dose desired (i.e. the drug dose ordered by the physician) H = dose on-hand (i.e. the drug dose on the label of the drug container) V = volume (i.e. the form and amount in which the drug comes) When

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