PCCA CONFIDENTIAL Form
Today's date Invalid Input
Name Invalid Input
Date of Birth Invalid Input
Age Invalid Input
Address Invalid Input
City Invalid Input
State Invalid Input
Zip Invalid Input
Phone Invalid Input
E-Mail Address Invalid Input
Gender Invalid Input
Height Invalid Input
Weight Invalid Input
Do you use tobacco? Invalid Input
Do you use alcohol? Invalid Input
Do you use caffeine? Invalid Input
How often and how much? Invalid Input
Allergies: Please check all that apply

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Others: Invalid Input
PATIENT NAME: Invalid Input
Medical Conditions/Diseases: Please check all that apply to

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Please list: Invalid Input
Current Prescription Medications:
Medication Name Invalid Input
Strength Invalid Input
Date Started Invalid Input
How often per day Invalid Input
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List Hormones previously taken.
Date Started
Date Stopped
Reason
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Have you ever used oral contraceptives? Invalid Input
Any problems? Invalid Input
If YES, describe any problem(s). Invalid Input
PATIENT NAME: Invalid Input
How many pregnancies have you had? Invalid Input
How many children? Invalid Input
Any interrupted pregnancies? Invalid Input
Have you had a hysterectomy? Invalid Input
If Yes(Date of Surgery) Invalid Input
Ovaries removed? Invalid Input
Have you had a tubal ligation? Invalid Input
If yes ligation(Date) Invalid Input
Do you have a family history of any of the following?
Uterine Cancer Invalid Input
Family member(s) Invalid Input
Ovarian Cancer Invalid Input
Family member(s) Invalid Input
Fibrocystic breast Invalid Input
Family member(s) Invalid Input
Breast Cancer Invalid Input
Family member(s) Invalid Input
Heart Disease Invalid Input
Family member(s) Invalid Input
Osteoporosis Invalid Input
Family member(s) Invalid Input
Have you had any of the following tests performed? Check those that apply and note date of last test.
Mammography Invalid Input
Date: Invalid Input
PAP Smear Invalid Input
Date: Invalid Input
Since you first began having periods, have you ever had what YOU would consider to be abnormal cycles? Invalid Input
Date Invalid Input
When was your last period? Invalid Input
How many days did it last? Invalid Input
Do you have, or did you ever have Premenstrual Syndrome (PMS)? Invalid Input
If YES, explain symptoms: Invalid Input
PATIENT NAME: Invalid Input
How did you arrive at the decision to consider Bio-Identical Hormone Replacement Therapy?
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What are your goals with taking BHRT? Invalid Input
Patient Name: Invalid Input
HORMONE REPLACEMENT THERAPY PATIENT INFORMATION SHEET
Fibrocystic Breast
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Weight Gain
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Heavy/Irregular menses
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Hot Flashes
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Dry Skin/Hair
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Anxiety
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Depression
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Night Sweats
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Vaginal Dryness
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Headaches
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Irritability
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Mood Swings
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Breast Tenderness
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Sleep Disturbances/Insomnia
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Cramps
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Fluid Retention
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Breakthrough Bleeding
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Fatigue
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Loss of Memory
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Bladder Symptoms
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Arthritis
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Harder to Reach Climax
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Decreased Sex Drive
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Hair Loss
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Patient Name: Invalid Input