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True You Hormone Health Profile

Thank you for your interest. In order to facilitate your first visit, it is very helpful to
complete this health profile before hand. Please answer each question as you see fit.
For the history portion please give an account of your current illness or problem(s) in
your own words. Feel free to go back as far as necessary in your life and history.
Your Name____________________________________ Date____________
DOB:__________________________
Tel: _______________ Fax: _________________ E-mail:_______________
Address:_______________________________________________________
City: _________________________ State:______ Zip:__________________
Primary Physicians name ______________________________Phone:_____________
Referred By: _____________________Relationship: ______________________
Tel: _________________________
SECTION I: OVERVIEW
1) My Most Important Problem Is:
_______________________________________________________________
_______________________________________________________________
2) What have other doctors thought was the main cause or diagnosis?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
3) Do you agree? Yes, largely ____ No____
What do you think is likely to be the main problem or diagnosis (or aspect of
your problem that might have been overlooked)?
_______________________________________________________________
_______________________________________________________________
4) Describe the time and circumstances when the main problem(s) first appeared
and/or worsened
________________________________________________________________
________________________________________________________________
________________________________________________________________
5) Are you currently working or in school?______ What do you do?___________

________________________________________________________________
6) Do your symptoms limit your effectiveness?____________________________
7) Current Medicines (include non-prescription and hormones)_______________
_____________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Current vitamins/herbs_________________________
________________________________________________________________
________________________________________________________________
8) Allergies_______________________________________________________
9) Medicines Not Tolerated_____________________________________________
10) Are you concerned about possible side-affects from any of your medicines?____
Which ones?______________________________________________________
________________________________________________________________
11) Did any of your important symptoms worsen within a few weeks of starting or
changing the dose of a medicine?______________________________________
________________________________________________________________
12) Past History
Surgery

Oophorectomy
Hysterectomy
Tubal Ligation
Prostate
Cancer related

Date of Surgery:
_________ (ovaries)
_________ (uterus)
__________
__________
_____________

Serious non-surgical illnesses


1.
2.
3.
Please indicate any diseases or disorders that run in your family and who has(d) them: (mother,
father, brother, sister, grandmother, or grandfather)
Asthma
Heart disease
High cholesterol
High blood pressure

Stroke
Blood clots
Arthritis
Lupus
Diabetes
Cancer
Fibromyalgia
Migraine headaches
Osteoporosis
AIDS or tuberculosis
Colitis or Crohns disease
Seizures
Multiple Sclerosis
ADD/ADHD
Depression
Thyroid disorders
Mononucleosis
PMS
Heartburn or reflux disease
Ulcers
Yeast infections
Shingles
Glaucoma
Other familial illness
Hormone related info:
Fibrocystic Disease
Fibroids
Abnormal Vaginal Bleeding
Smoking History
Stroke
Impaired Liver Function
Endometriosis
Primary Health
When was your last physical exam?
Pap/pelvic
Mammogram
Prostate exam
Hemoccult test
Colon exam
Bone scan
Other:

To what degree do you experience the following?


None

Slightly

Moderate

Severe

Extreme

None

Slightly

Moderate

Severe

Extreme

None

Slightly

Moderate

Severe

Extreme

Difficulty Concentrating
Cant Sleep (Insomnia)
Depressed or Unhappy
Anxious
Headaches
Moodiness/Emotional Swings
Painful or Swollen Breasts
Weight gain/ Bloating
PMS

Night Sweats
Difficulty Remembering Things
Hot Flashes
Vaginal Dryness
Dry Hair/Skin
Incontinence
Frequent Urinary Tract Infections
Inability to Reach Orgasm
Painful Intercourse
Difficulty urinating
Lack of Sexual Desire
Fatigue/Loss of Energy
Erectile Difficulty

General Health:
Good
Fair
Poor
Height: ______________________
Weight: ______________________
Periods:
None
Regular_____________
Irregular_____________

Explain (heavy, how long,etc) _______________

DIET
How do you rate your diet: Excellent_____ Good_____ Fair_____ Poor_____

About how many times in an average week do you eat:


Green leafy vegetables (excluding lettuce) _____ Yellow vegetables
(carrot/squash/sweet potato) _____ Berries_____ Fruit_____ Fish_____
Yogurt_____ Milk/cheese_____ Ice cream_____ Chocolate_____ Beef/pork_____
Chicken/turkey_____ Salad dressing or vegetable oil_____ Soy_____
Nuts/beans/seeds_____
How many times a week do you: Eat at home_____ In a restaurant_____ Skip
breakfast_____ Skip lunch_____ Skip dinner_____
Do you consciously try to reduce your intake of: Sugars _____
Other carbohydrates_____ Artificial sweeteners_____ Caffeine_____
Alcohol_____ Protein_____ Why?_______________________________________
Do you restrict your fats? Yes _____ No _____
Do the following foods often help you feel Better (B) or Worse (W)? Sugar_____
Starch_____ Alcohol_____ Caffeine_____ Milk products_____
Fatty foods_____ Organic food_____ Yeast/mold_____ Additives_____
Wheat/gluten_____ Chocolate_____ Garlic/onion_____ Spices_____
Deli meats_____ MSG_____ Artificial sweeteners_____
Do you avoid certain foods because you suspect you are allergic or do not tolerate
them? _____ Which?________________________________________________
Have you had food allergy testing? _____ What kind of test? _____
What were the results? _______________________________________________
Are these results generally consistent with your experience? _________________
HABITS AND LIFESTYLE: Please circle or list which of the following you use:
tobacco/cigarettes/chewing tobacco/ recreational drugs/ Other:
________________________________________
How often do you use these substances? _________________________________
CAFFEINE
How many cups/glasses per day do you drink of:
Coffee_____ Decaff coffee_____ Tea_____ Herbal tea_____ Cola drinks_____
Other soft drinks_____
If you drink caffeinated drinks regularly, have you abstained completely from
caffeine for two days or more since you have been ill?_____ If so, what
happened? _________________________________________________________
Examples of what you eat for
Breakfast
Lunch
Dinner

Snacks

__________________________________________________________________________
Waiver
I hereby release True You Hormones, Inc,, all its employees and pharmacists from any and all
liability whatsoever associated with or connected to my Lifestyle Management or Biologically
Identical Hormone Replacement Therapy (BHRT) consultation and/or use. I acknowledge that I
am legally responsible for and aware of the potential side effects associated with Lifestyle
Management or BHRT. I understand that no doctor, nurse, pharmacist, or administrative
personnel can guarantee that Lifestyle Management or BHRT will provide the results I seek. I am
participating in this program by my own choice, and assume all responsibility for my use of Lifestyle
Management or BHRT.
I fully understand that it is my responsibility to have an annual physical examination along with appropriate
laboratory testing. I am currently under the medical supervision of a primary care physician. I have been
advised in this hormone questionnaire about the increased risks of heart disease, myocardial infarction,
stroke, and breast cancer possibly associated with the use of BHRT. I have answered truthfully all of the
questions on this questionnaire.
Signed___________________________________________________ Date ______________

Privacy Agreement
Starting April 14, 2003, health care providers must comply with a new set of federal regulations. The
regulations are part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which
addresses your rights to privacy and handling of Protected Health Information (PHI).
Respect for your privacy is a top priority at The Herb Doctor. Concern for your privacy rights goes hand in
hand with our focus on maintaining and improving your health.
One of the new regulations requires that all of our patients receive our Notice of Privacy Practices at the time
of or prior to our providing health care services. We are also required to ask each patient to sign an
acknowledgment indicating receipt of this notice.
If you have questions regarding this letter or privacy issues in general, please contact 1-800-476-6130,

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES


____________________________________________ ______________________________
Patient Last Name
Patient First Name
_________________________________________________________
Street Address
City
_____________
Zip

___
M.I.

___________________
State

(______)_________________
Telephone Number

My signature below certifies that I have been provided with a written copy of the above
named pharmacys Notice of Privacy Practices.
________________________________________________
Patient Signature (or authorized representative)

________________
Date