Individual Bio-Identical Hormone Consultation
Patient Intake Information
(Please print clearly)
Contact Information:
Patient Name:__________________________________ DOB________________
Mailing Address:_________________________________________Zip:________
Home Phone:_________________________ Check OK to leave detailed message ___OK
Cell Phone:___________________________Check OK to leave detailed message ___OK
Work Phone:__________________________Check OK to leave detailed message ___OK
Email Address:_________________________________________________________
Practitioner Information:
Name:__________________________________________________________________
Address:________________________________________________________________
Phone:_________________________________________________________________
Fax:____________________________________________________________________
Email Address:___________________________________________________________
Website:________________________________________________________________
Referral? Yes____ No_____
Billing Information: (Card numbers kept confidential, If no CC number given, patient will be billed)
Billing Address:____________________________________Zip Code________________
Credit Card Number__________________________Exp Date_______Sec Code_______
Name as written on Credit Card:_____________________________________________
Would you like your bill/statement sent via Email instead of mail?____Yes ____No
Are you a Medicare Patient? ______Yes ______No
***Please Read and Sign:***
*If appointment needs to be rescheduled, please call Brynna at 669-7500 ext 8 at least 24 hours in advance or a $30 fee will be charged to patient.
*I understand that NO payment is asked for up front. Billing information will be processed weekly through Holistic Health Options, Inc. Payment is appreciated in full within 15 days of appointment. If not possible, please call Brynna at 669-7500 ext 8 to arrange other payment options. If bill is not paid within 90 days, it will be sent to collections. (Don't worry...Just a legal thing to write that and Lori has never had to do this)
*Fee Schedule: $150/60min. Additional time spent with patient will be billed in increments of $50/15min. Minimum fee assessed will be $50. Patient will be billed for time spent either by phone or in person. Email responses by Lori that require a recommendation to a practitioner will be billed to the patient at Lori’s discretion.
*Authorization to Release Medical Information: I hereby authorize Holistic Heath Options or Good Day Pharmacy and any licensing organizations to review and obtain copies of my medical record (e.g., medical history, prescription formulas, patient notes, patient lab tests, etc.) and insurance information, as they relate to my therapy, to my reimbursement to Holistic Health Options, Good Day Pharmacy, and for care coordination, quality assurance, accreditation, or licensing reviews. I also hereby authorize Holistic Health Options or Good Day Pharmacy to furnish to my insurance carriers and other health care providers, any medical history, lab testing, proof of services rendered, or plan of care recommended. I understand that these authorizations take effect immediately and that a fax or photocopy is valid as the original.
*I have read and understand all of the information stated above.*
SIGNED________________________________________
THANK YOU!
LORI FINNICK, RPH, BIO-IDENTICAL HORMONE CONSULTANT
HOLISTIC HEALTH OPTIONS, INC.
GOOD DAY PHARMACY
*Revised 06/2008
Bio-Identical Hormone Replacement
Confidential Evaluation
From a clinical management point of view, it is very useful to gain a detailed history of possible hormone deficiencies. The answers provided in the questions below will allow me to maintain your medical history and will help in advising about current hormone therapies. All information provided will be kept confidential.
Date:______________________
GENERAL INFORMATION****************************************************
Name:__________________________________Age:_________Birthdate:_________________ Address:______________________________________________________________________
Phone #1:___________________ext______ Phone#2:__________________________Ext:_____
E-Mail Address:______________________________________________________________
Occupation:_____________________Full-time:___Part-time:___Other:___________________
Status: Married__ Single__ Divorced__ Widowed__ Children:______________________________________________________________________ Pets:__________________________________________________________________________
How did you hear about Natural Hormone Replacement Therapy? Ad_____ Another Patient____ Courses/Seminars____ Physician/Healthcare Practitioner____ Books/Articles____ Other______
Do you understand what Natural Hormone Replacement is?______________________________
_______________________________________________________________________________
What are your goals for Natural Hormone Replacement?________________________________
______________________________________________________________________________
MEDICAL STATUS************************************************************
General Health: Excellent__Good__Fair__Poor__ Height:_________ Weight:_____________
Current diagnosis or medical conditions:_____________________________________________
Drug Allergies:_________________________________________________________________
Allergies to food, pollens, etc.:_____________________________________________________
Current Medications (including hormone therapies):____________________________________
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(Page 2)
Current Vitamins or OTC Products:_________________________________________________
Current Herbs/etc.:______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Have you ever had your cholesterol level checked?_____Date:_____Results:________________
Have you ever had a mammogram?_________________ Date:_____Results:________________
Have you ever had a bone density scan?_____________ Date:_____Results:_______________
Current/Recent Health Care Providers (phone numbers if possible):________________________
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PAST MEDICAL CONDITIONS*************************************************
Childhood Diseases:_____________________________________________________________
Heart Trouble_____High Blood Pressure_____Stroke_____Varicose Veins_____Clotting _____
Diabetes_____Kidney Problems_____Epilepsy_____Fractures_____Arthritis_____Colitis_____
Gallbladder Trouble_____Asthma_____Chronic Fatigue_____Fibromyalgia_____Cancer______
Eating Disorder_____Other_______________________________________________________
HABITS*******************************************************************************************************
Dietary Restrictions:_______________________________________________________________
Meal Choices: Breakfast:___________________________________________________________
Lunch:______________________________________________________________
Dinner:______________________________________________________________
Do you get routine physical exercise?_____What type?___________________________________
Do you use tobacco products?_____How much?_______Previously?______How long?__________
Do you use alcohol products?_____How much?_____Previously?_______How long?___________
Do you use caffeine products?_____How much?_________________________________________
FAMILY HISTORY************************************************************
Please list family members and important diseases such as high blood pressure, heart disease,
cancer, diabetes, osteoporosis, etc.:__________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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(Page 3)
GYNECOLOGICAL HISTORY**************************************************
Age at first period:_______________________ Date of last period:_______________________
Date of last pelvic exam:__________________ Pap smear:________ Results:_______________
Have you ever had an abnormal pap?_________ Treatment:_____________________________
Are you sexually active?___________________ Are you trying to get pregnant?_____________
Current birth control method:________________ How long?_____________________________
__Problem with it?_________________________ How long?_____________________________
Past birth control and any related problems:__________________________________________
How many days from start of one period to the start of the next?__________________________
Number of days of flow:________________________ Amount of bleeding:_________________
Amount of cramps:______________________________________________________________
Premenstrual symptoms:__________________________________________________________
Starting and ending when?________________________________________________________
Any current changes in your normal cycle?___________________________________________
Any bleeding between periods?_____________ When?_________________________________
Any pelvic pain, pressure or fullness?__________ Describe:_____________________________
Any unusual vaginal discharge or itching?_______ Describe:_____________________________
__Treatment:___________________________________________________________________
Age at first pregnancy:___________________________________________________________
How many full term pregnancies?_____________ Problems:_____________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Any interrupted pregnancies? (Miscarriages or abortions)_______________________________
______________________________________________________________________________
_______________________________________________________________________________
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Have you had a tubal ligation?_____ When?__________________________________________
Have you had any part or whole ovary removed?______________ When?___________________
Have you had a hysterectomy?_________When?______________________________________
Do your ovaries remain?__________________________________________________________
Explanations to any of above questions______________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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(Page 4)
SYMPTOMS******************************************************************
Rate your current status for each symptom by checking the appropriate box.
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1. Headaches
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2. Hot Flashes
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3. Night Sweats
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4. Low Libido
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5. Vaginal Dryness
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6. Anxiety
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7. Swollen Breasts
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8. Painful Intercourse
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9. Fibrocystic Breasts
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10. Moodiness
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11. Depression
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12. Food Cravings
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13. Irritability
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14. Sleep Disorders/Insomnia
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15. Cramps
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16. Uterine Fibroids
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17. Emotional Swings
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18. Premenstrual Menses
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19. Heavy/Irregular Menses
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20. Weight Gain
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21. Water Retention/Edema
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22. Bloating (gas)
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23. Frequent Urinary Tract Infections
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24. Frequent Yeast Infections
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25. Inability to Concentrate
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26. Fuzzy Thinking
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27. Fatigue/Lack of Energy
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28. Short Term Memory Loss
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29. Heart Palpitations
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30. Shortness of Breath
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31. Dry Hair/Dry Skin
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32. Hair Loss
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33. Loss of Pubic Hair
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34. Painful Intercourse
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35. Inability to Reach Orgasm
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36. Urinary Frequency (Nighttime)
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(Page 5)
CONSULTATION NOTES******************************************************
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PATIENT CONTACT INFORMATION
***The HIPAA privacy rule provides the patient with the right to request confidential communications or that a communication of Protected Health Information (PHI) be made by alternative means, such as sending correspondence to the individual’s office instead of to the individual’s home.
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Corporate office: Good Day Pharmacy 653 Denver Ave., Loveland, CO 80537