partellmedrx.com: Consultations

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If you would like to have a personalized and confidential hormone consultation, please fill out the form below and one of our trained consultants will get right back to you! Or, you can always call us directly and schedule an appointment at 702-791-3800.

Hormone Consultation

Date *

Name *

Age *

Bithdate *

City *

State/Province *

Zip/Postal Code *

Email *

Home Phone *

Work Phone

Fax *

Occupation

What is your greatest need or problem? ( List the most important; then list other issues in order of importance) *

Your current medical conditions or diagnoses *

Drug Allergies

Allergies to food, pollens, environment, etc.

Names of ALL prescription medications, taken in last 6 months. Include strength and how you take them

Indicate any herbal products you have taken: (Evening Primrose Oil (EPO), Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc): Other:

Names of ALL Vitamins, Supplements, Non-prescription medicines, or other OTC products that you are currently using:

If you are you currently taking medication for a thyroid condition, which one and dose?

Have you ever had a bone density scan?

When?

Results

Do you use tobacco products?

What?

How Much?

For How Long?

Do you use alcohol products?

What?

How Much?

For How Long?

Do you use caffeine products?

What?

How Much?

Do you use recreational drugs?

What?

How Much?

How much water do you drink in one day (24 hr)? oz. or glasses?

Is your drinking water from a:

Dietary Restrictions (such as salt, carbohydrates, milk products, red meat, etc):

When was your last: General medical exam:

When was your last : Pelvic exam:

Have you ever had an abnormal Pap?

Treatment

At what age was your first period (menarche)?

When was your most recentor last period (LMP):

Do you still have your period?

If Yes, how many days from the start of one period to the start of the next

Number of days of flow:

Amount of bleeding:

Describe any cramping or pain you may have:

Do you have pain at any other time in your cycle

Where, when, how long?

Any current changes in your normal cycle?

Any bleeding between periods (IMB):

When and describe:

What were your periods like as a teenager?

If you have ever had Premenstrual Symptoms (PMS), please describe:

How long have you had PMS symptoms?

Starting and ending when:

If your periods have ever been difficult, irregular, or abnormal in any way, please describe:

If you are you currently having any pelvic pain, pressure, or fullness, describe:

Describe any recent unusual vaginal discharge or itching:

Treatment for any of above:

Have you had Tubes tied (tubal ligation)?

When? and at what age?

Have you had Uterus removed (hysterectomy)?

When? Why?

Have you had Ovaries removed (oophorectomy)?

If yes or part, What? When? Why?

Were there any problems associated with the surgery or removal of any of these organs?

Has your doctor diagnosed menopause, or told you that you are in menopause?

If yes, at what age?

If at age 40 years or earlier, was Premature Ovarian Failure, diagnosed?

Have you ever been pregnant?

How many times have you been pregnant (gravida)?

Are you trying to get pregnant?

What was your age at your first pregnancy?

Any problems?

How many pregnancies resulted in the birth of living children (para)?

Were there any problems?

Any interrupted pregnancies (miscarriages or abortions)?

Current birth control method: How long?

Any problems?

Have you ever used any of the following birth control methods: Oral Contraceptives (Birth Control Pills)

Total months/years used: Describe any side effects to Birth Control Pills:

Intra-Uterine Device (IUD)

Problems?

When was your last mammogram?

Results:

Do you examine your breasts monthly?

Have you ever experienced breast pain, discomfort, nipple discharge, or swelling other than when pregnant? Give details:

Have you ever been diagnosed with lumps, fibroids, breast cancer, or similar breast conditions?

If your doctor has recently ordered lab tests or diagnostic procedures for you, please give details, including whether the test or procedure was performed, and the results:

CHECK A BOX FOR EACH SYMPTOM which best describes how you have been feeling for the past 3 weeks.

0 = None (symptom not present)
1 = Mild (present but not distressing)
2 = Moderate (distressing, but not interfering with daily life)
3 = Severe (very distressing, interferes with daily life)

If you wish to add comments or details, please send by separate email to our pharmacy, indicating your first and last name in the email. Thank you.

Hot flushes

Night sweats

Light-headed feelings/dizziness

Headaches

Sleep disorders/Sleeplessness

Unusual tiredness/Fatigue

Irritability

Depression

Anxiety/Tension/Nervousness

Mood swings/Mood changes

Confusion/Difficulty concentrating

Forgetfulness/Short-term memory loss

Angry outbursts/Arguments/ Violent tendencies

Crying easily

Backache

Joint pains

Muscle pains

Muscle cramps/spasms

Problems with wound healing time

Acne/Pimples/Skin flushing

New facial hair

Dry skin/Dry hair

Crawling feeling under skin

Frequent Urinary Tract Infection (UTI)

Urinary frequency

Vaginal dryness

Abnormal bleeding

Pelvic pain, pressure, fullness, or bloating

Uncomfortable intercourse

Loss of sexual feeling/desire

Loss of arousability & capacity for orgasm

Loss of sexual sensitivity

Loss of vitality

Nipple sensitivity

Discharge or leaking from nipples

Breast tenderness

Loss of pubic hair

Swelling of hands, ankles, or breasts

Heart palpitations

Shortness of breath

Food /sweets /salt cravings

Increased appetite/weight gain

Tightness in neck/shoulders

Visual disturbance or decreased vision

Difficulty hearing

Diminished sense of taste

Diminished sense of smell


Partell Specialty Pharmacy on Facebook	If you would like to have a personalized and confidential hormone consultation, please fill out the form below and one of our trained consultants will get right back to you! Or, you can always call us directly and schedule an appointment at 702-791-3800. Hormone Consultation Date * Name * Age * Bithdate * City * State/Province * Zip/Postal Code * Email * Home Phone * Work Phone Fax * Occupation What is your greatest need or problem? ( List the most important; then list other issues in order of importance) * Your current medical conditions or diagnoses * Drug Allergies Allergies to food, pollens, environment, etc. Names of ALL prescription medications, taken in last 6 months. Include strength and how you take them Indicate any herbal products you have taken: (Evening Primrose Oil (EPO), Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc): Other: Names of ALL Vitamins, Supplements, Non-prescription medicines, or other OTC products that you are currently using: If you are you currently taking medication for a thyroid condition, which one and dose? Have you ever had a bone density scan? When? Results Do you use tobacco products? What? How Much? For How Long? Do you use alcohol products? What? How Much? For How Long? Do you use caffeine products? What? How Much? Do you use recreational drugs? What? How Much? How much water do you drink in one day (24 hr)? oz. or glasses? Is your drinking water from a: Dietary Restrictions (such as salt, carbohydrates, milk products, red meat, etc): When was your last: General medical exam: When was your last : Pelvic exam: Have you ever had an abnormal Pap? Treatment At what age was your first period (menarche)? When was your most recentor last period (LMP): Do you still have your period? If Yes, how many days from the start of one period to the start of the next Number of days of flow: Amount of bleeding: Describe any cramping or pain you may have: Do you have pain at any other time in your cycle Where, when, how long? Any current changes in your normal cycle? Any bleeding between periods (IMB): When and describe: What were your periods like as a teenager? If you have ever had Premenstrual Symptoms (PMS), please describe: How long have you had PMS symptoms? Starting and ending when: If your periods have ever been difficult, irregular, or abnormal in any way, please describe: If you are you currently having any pelvic pain, pressure, or fullness, describe: Describe any recent unusual vaginal discharge or itching: Treatment for any of above: Have you had Tubes tied (tubal ligation)? When? and at what age? Have you had Uterus removed (hysterectomy)? When? Why? Have you had Ovaries removed (oophorectomy)? If yes or part, What? When? Why? Were there any problems associated with the surgery or removal of any of these organs? Has your doctor diagnosed menopause, or told you that you are in menopause? If yes, at what age? If at age 40 years or earlier, was Premature Ovarian Failure, diagnosed? Have you ever been pregnant? How many times have you been pregnant (gravida)? Are you trying to get pregnant? What was your age at your first pregnancy? Any problems? How many pregnancies resulted in the birth of living children (para)? Were there any problems? Any interrupted pregnancies (miscarriages or abortions)? Current birth control method: How long? Any problems? Have you ever used any of the following birth control methods: Oral Contraceptives (Birth Control Pills) Total months/years used: Describe any side effects to Birth Control Pills: Intra-Uterine Device (IUD) Problems? When was your last mammogram? Results: Do you examine your breasts monthly? Have you ever experienced breast pain, discomfort, nipple discharge, or swelling other than when pregnant? Give details: Have you ever been diagnosed with lumps, fibroids, breast cancer, or similar breast conditions? If your doctor has recently ordered lab tests or diagnostic procedures for you, please give details, including whether the test or procedure was performed, and the results: CHECK A BOX FOR EACH SYMPTOM which best describes how you have been feeling for the past 3 weeks. 0 = None (symptom not present) 1 = Mild (present but not distressing) 2 = Moderate (distressing, but not interfering with daily life) 3 = Severe (very distressing, interferes with daily life) If you wish to add comments or details, please send by separate email to our pharmacy, indicating your first and last name in the email. Thank you. Hot flushes Night sweats Light-headed feelings/dizziness Headaches Sleep disorders/Sleeplessness Unusual tiredness/Fatigue Irritability Depression Anxiety/Tension/Nervousness Mood swings/Mood changes Confusion/Difficulty concentrating Forgetfulness/Short-term memory loss Angry outbursts/Arguments/ Violent tendencies Crying easily Backache Joint pains Muscle pains Muscle cramps/spasms Problems with wound healing time Acne/Pimples/Skin flushing New facial hair Dry skin/Dry hair Crawling feeling under skin Frequent Urinary Tract Infection (UTI) Urinary frequency Vaginal dryness Abnormal bleeding Pelvic pain, pressure, fullness, or bloating Uncomfortable intercourse Loss of sexual feeling/desire Loss of arousability & capacity for orgasm Loss of sexual sensitivity Loss of vitality Nipple sensitivity Discharge or leaking from nipples Breast tenderness Loss of pubic hair Swelling of hands, ankles, or breasts Heart palpitations Shortness of breath Food /sweets /salt cravings Increased appetite/weight gain Tightness in neck/shoulders Visual disturbance or decreased vision Difficulty hearing Diminished sense of taste Diminished sense of smell
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