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Initial Chief Complaint
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Referred By
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Primary Pharmacy
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Insurance
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Medical History
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Health History
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Past Medical History Freewrite
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Have you recently had:
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Other Medical Conditions
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Past Surgical History
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Comments
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Previously diagnosed with
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If previously on HRT, When/What/Outcome
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Prescription Medications
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Dose
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Prescription Medications
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Dose
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Prescription Medications
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Dose
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Prescription Medications
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Dose
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Prescription Medications
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Dose
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Other prescriptions:
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Screening
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Bone Density
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Date / Results
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Colonoscopy
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Date / Results
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Prostate Exam
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Date / Results
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Complete Physical
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Date / Results
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Mammogram
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Date / Results
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Pap Smear
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Date / Results
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Other testing
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Major Events
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Hospitalizations, surgeries, births, cosmetic
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Event / Date:
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Event / Date:
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Event / Date:
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Event / Date:
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Family History
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Father's MH
• • •
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Comments
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Mother's MH
• • •
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Comments
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Sibling(s)' MH
• • •
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Comments
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Grandparent's MH
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Comments
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Children(s)' MH
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Comments
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Social History
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Marital Status
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Any children? What ages?
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Stress Level
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Source of stress:
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Sexual Hx
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Libido Scale 1-5:
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Alcohol
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If yes, what kind and how much?
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Drug Use:
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If yes, what kind and how much?
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Tobacco Use:
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If yes, how frequent?
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Motivation:
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Hormone Evaluation
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Hormone Evaluation
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Age of first period:
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LMP
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Number of miscarriages:
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P/G:
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Natural or IVF?
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Difficulty Conceiving?
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Vaginal Delivery or C-Section?
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Contraception?
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If yes, what kind?
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Ovaries
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Hysterectomy
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Average length of menstrual cycle:
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Have you ever had?
• • •
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Pt has been told she may have PCOS
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Progesterone/Metformin?
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Sexually active?
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How is your libido, on a scale 1-5?
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Body satisfaction during sex
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Lifestyle & Nutrition
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Weight Info
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Height:
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Current Weight:
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Lowest Adult Weight:
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Goal Weight:
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Were you overweight as a child
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Sleep Patterns
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Hours of sleep
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Falls asleep easily
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Sleep Aids
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Often wakes during sleep
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Dreams at night
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Snores at night
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Feelings
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Sleep Comments
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Nutrition Evaluation
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Defecation per week
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Strain when defecating
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Consistency of stools
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Often holds stools in
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Describe current diet
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Does Pt follow diet plan?
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Breakfast Description:
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Lunch Description:
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Dinner Description:
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Snack Description:
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Does Pt cook?
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Dessert Description & Frequency:
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Number of meals per day:
• • •
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Number of snacks per day:
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Weekly fruit intake
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Weekly veggie intake:
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Eats red meat
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If yes, how many times/week?
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Eats dairy
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If yes, how many times/week?
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Eats white starches
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If yes, how many times/week?
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Eats butter
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If yes, any specific time of day/month?
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Food Aversions:
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Awaken during the night hungry
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Food cravings:
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If yes, what do you do?
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Is your partner or spouse overweight? How much?
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Do you eat out? If yes, how often?
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Dietary Habits:
• • •
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Able to shop at whole foods groceries:
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Water intake per day:
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Other Liquids and Frequencies:
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Alcoholic Beverages:
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Beverage comments:
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Nonalcoholic drinks on a regular basis
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Fitness Evaluation
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Activity Level
• • •
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Description of exercise routine:
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How long on this routine:
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Other Physical Activities
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How often do you exercise?
• • •
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What kind of exercise do you do?
• • •
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