|
Patient Check-in
|
|
|
HPI (see pertinent continuity of care for details)
|
|
|
HPI
|
|
|
PE (if applicable)
|
|
|
Physical Exam (if applicable)
|
|
|
Were labs drawn since last treatment?
|
|
|
Key Lab Review Findings
|
|
|
Lab Flow
|
|
|
Review of Systems
|
|
|
Current Symptomatology
|
|
|
Overall is patient feeling better or worse?
|
|
|
Assessment / Diagnoses
|
|
|
Non Gender Specific Diagnosis
• • •
|
|
|
Female Hormone Diagnosis
• • •
|
|
|
Male Hormone Specific
• • •
|
|
|
Other (details):
|
|
|
Treatment / Plan
|
|
|
Hormone Optimization
|
|
|
Pellet Procedure
|
|
|
Pellet Procedure Details
|
|
|
Details
|
|
|
Prep solution
• • •
|
|
|
Local Anesthetic
|
|
|
1% lido w/ epi quantity
|
1% lido no epi quantity
|
|
Sodium bicarbonate quantity
|
Other:
|
|
Insertion site
|
Other
|
|
Pellet (type and quantity)
|
Pellet Lot #
|
|
Plan for Pharmaceuticals
|
|
|
Pharmaceuticals
|
|
|
Recommended Nutraceuticals / Supplements
|
|
|
Recommended Supplements
• • •
|
|
|
Other
|
|
|
Follow up Details
|
|
|
Monitoring
|
|
|
Date of Last Labs
|
|
|
Date of Next Labs
|
|
|
Lab Requisition Form
|
Other
|
|
Date of Next Appointment
|
|
|
Additional Plan Details
|
|
|
Patient Education
|
|
|
BHRT Patient Medication Information
|
|
|
Benefits / Alternative Therapies
|
|
|
Procedure Aftercare / Expectations
|
|
|
BHRT Supplement Information/Education
|
|
|
Patient Education (Other)
|
|
|
Nervana Contact Information
|
|
|
Provider
|
|
|
Provider
|
MA / Assistant (Charted by)
|
