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Patient Information:
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VITALS
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ESTABLISHED PATIENT
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NEW PATIENT
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MRA
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MRA - HORMONE
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INJECTIONS
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TELEMEDICINE
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LABS
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EKG
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E-SCRIPT /MISCELLANEOUS
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E-SCRIPT/MISCELLANEOUS
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E-SCRIPT
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Notes
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Topamax
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Diuretic / B/P Medications
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Mood Stablizers
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Sleep Aids
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Thyroid Medication
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Other Medications
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Other Rx
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Notes
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Pharmacy
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Other Pharmacy
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PMP
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Notes
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MRA
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Mail / In-office
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MEDICATION REFILL
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Current Weight: ALSO CHART IN VITALS
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Current BP: ALSO CHART IN VITALS
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Any Medical or Medicine Changes?
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Eating/Exercise habits during past month:
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Have the medications been effective? HOW?
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Any Side Effects?
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LIPO-B
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Initials and Lot #
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Standing Order
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Supplements
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Supplement Notes:
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Phentermine
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Adipex-P
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Phendimetrazine
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Diethylpropion
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Benzphetamine
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Topamax
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Diuretic / B/P Medications
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Mood Stablizers
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Sleep Aids
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Thyroid Medication
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Other Medications
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Other Rx
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Pharmacy
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Other Pharmacy
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PMP
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Notes
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MRA - HORMONE
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Mail / In-office
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MEDICATION REFILL
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Current Weight: ALSO CHART IN VITALS
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Current BP: ALSO CHART IN VITALS
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Any Medical or Medicine Changes?
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Have you had any adverse effects with your bio-identical hormone therapy?
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Have you noticed any improvement in the way you feel using bio-identical hormone therapy?
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Any other information or feelings you would like to list at this time?
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Testosterone IM
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Other Rx
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BHRT CREAM - MALE
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Other Rx
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BHRT CREAM - FEMALE
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Other Rx
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Progesterone
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Other Rx
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Anastrozole
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Other Rx
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Other Rx
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Prescription notes & reminders
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Pharmacy
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Other Pharmacy
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PMP
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Comments
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ESTABLISHED PATIENT
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Reviewed Labs
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Lab Notes
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EKG Reviewed
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EKG reporting
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LIPO-B
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Initials and Lot #
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PLAN (no issues)
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PLAN (CHANGES)
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Diet/Nutrition Recommendations
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Diet/Nutrition Recommedations
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Exercise Recommendations
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Exercise Recommendations
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Referrals/Recommendations
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Referrals/Recommendations
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Supplements
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Supplement Notes
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Phentermine
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Other Rx
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Adipex-P
• • •
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Other Rx
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Phendimetrazine
• • •
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Other Rx
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Diethylpropion
• • •
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Other Rx
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Benzphetamine
• • •
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Other Rx
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Topamax
• • •
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Other Rx
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Diuretic / B/P Medications
• • •
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Other Rx
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Mood Stablizers
• • •
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Other Rx
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Sleep Aids
• • •
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Other Rx
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Thyroid Medication
• • •
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Other Rx
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Other Medications
• • •
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Other Rx
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Pharmacy
• • •
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Other Pharmacy
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PMP
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Notes
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NEW PATIENT
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New Patient / Back on Program
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New Patient Education / Discussion
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PLAN (Free Text) - USE Macro
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LIPO-B
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Initials and Lot #
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Lab Tests
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Lab Notes
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EKG Reviewed
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EKG reporting
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Diet / Nutrition Recommendations
• • •
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Diet/Nutrition Recommedations
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Exercise Recommendations
• • •
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Exercise Recommendations
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Referrals/Recommendations
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Referrals/Recommendations
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Supplements
• • •
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Supplement Notes
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Phentermine
• • •
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Other Rx
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Adipex-P
• • •
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Other Rx
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Phendimetrazine
• • •
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Other Rx
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Diethypropion
• • •
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Other Rx
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Benzphetamine
• • •
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Other Rx
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Topamax
• • •
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Other Rx
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Diuretic / B/P Medications
• • •
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Other Rx
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Mood Stablizers
• • •
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Other Rx
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Sleep Aids
• • •
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Other Rx
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Thyroid Medication
• • •
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Other Rx
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Other Medications
• • •
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Other Rx
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Pharmacy
• • •
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Other Pharmacy
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PMP
• • •
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Notes
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INJECTIONS
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LIPO-B
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Initials and Lot #
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Standing Order
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FLU SHOT
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Initials and Lot #
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CELESTONE / DRIZE
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Initials and Lot #
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OTHER INJECTION (Name)
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Initials and Lot #
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Telemedicine
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Telemed / Phone
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Reason for Televisit
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PLAN (no issues)
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PLAN (CHANGES)
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Diet / Nutrition (no issues)
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Diet/Nutrition Notes (Changes)
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Nutritional Recommendations
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Comments
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Supplements
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Supplement Notes
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Phentermine
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Other Rx
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Adipex-P
• • •
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Other Rx
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Phendimetrazine
• • •
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Other Rx
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Diethylpropion
• • •
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Other Rx
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Benzphetamine
• • •
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Other Rx
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Topamax
• • •
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Other Rx
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|
Diuretic / B/P Medications
• • •
|
Other Rx
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|
Mood Stablizers
• • •
|
Other Rx
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|
Sleep Aids
• • •
|
Other Rx
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|
Thyroid Medication
• • •
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Other Rx
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Other Medications
• • •
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Other Rx
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Pharmacy
• • •
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Other Pharmacy
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PMP
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Comments
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Hormones
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HORMONES
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Hormones (no changes)
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Hormones (changes)
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Current Symptoms
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Current Symptoms
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Adverse Effects
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Adverse Effects
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Improved Symptoms
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Improved Symptoms
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Has the patient noticed any improvement in the way they feel using BHRT?
• • •
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Testosterone IM
• • •
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Other Rx
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BHRT CREAM - MALE
• • •
|
Other Rx
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BHRT CREAM - FEMALE
• • •
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Other Rx
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Progesterone
• • •
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Other Rx
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Anastrozole
• • •
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Other Rx
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Other Rx
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Prescription notes & reminders
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Labs Reviewed
• • •
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Lab Comments
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Additional Lab
• • •
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Additional labs ordered
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Pharmacy
• • •
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Other Pharmacy
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PMP
• • •
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Comments
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BOTOX/FILLERS
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BOTOX / FILLERS
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Botox
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Risks of Neurotoxin Statement
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Botox Consent
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Consent Form Signed
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Procedure notes
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Total number of units
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Injection site
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Other injection site:
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Lot # / Expiration Date
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Glabella
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Units
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Forehead
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Units
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Crows feet
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Units
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Bunny Lines
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Units
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Other Injection Site:
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Units
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Post Procedure Bruising
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Additional notes
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Filler
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Filler Consent
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Does patient have history of HSV?
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Filler Type
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___ cc's
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Injection site
• • •
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Other injection site:
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Lot # / Expiration Date
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Additional notes
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Ice given?
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Anesthetic used
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Post Procedure Bruising or Swelling?
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NP/DR Consult
• • •
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Provider's Notes
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NP/DR Consult
• • •
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Provider's Notes
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NP/DR Consult
• • •
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Provider's Notes
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NP/DR Consult
• • •
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Provider's Notes
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NP/DR Consult
• • •
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Provider's Notes
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NP/DR Consult
• • •
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Provider's Notes
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NP/DR Consult
• • •
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Provider's Notes
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NP/DR Consult
• • •
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Provider's Notes
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Physicians
• • •
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Nurse Practitioners
• • •
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