NHRT Form

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NHRT Form

In order to provide the best NHRT service, please fill out the form below. Please fill out the form completely, if you have any questions, consult your physician or call us at (316) 685-2353.

If you prefer, download the form and return it to your local store.

Step 1 of 10

10%

Medical History Form
Please return this form to the Pharmacy when you have finished. The Pharmacist will meet you to review your information. Thank you.
Step 1 of 10: Pharmacist Progress Notes
Patient Name*
Initial Evaluation Date*
How did you hear about us (i.e. TV, Referral, Google)?
Phone #*
Address*
Primary Diagnosist*
Email Address*
Today's Date*
MM slash DD slash YYYY
Primary MD*
MD Phone #*
Chief Complaint/Problem TODAY*
Data (subjective/objective)*
Assessment*
Plan*

Step 2 of 10: Patient Information
First Name*
Last Name*
Phone Number*
Birthday*
Address
Street Address City ZIP / Postal Code
Insurance Company*
Height*
Weight*
Gender
- Male
- Female

Step 3 of 10: Lifestyle Information
Do you use
Tobacco (smoke, chew, dip)
- No
- Yes
If yes, how often and how much
Alcohol (beer, wine, hard liquor)
- No
- Yes
If yes, how often and how much
Caffeine (cola, drinks, tea, coffee)
- No
- Yes
If yes, how often and how much
Impairments ( check all that apply )
- Physical Impairment
- Visual Impairment
- Hearing Impairment
Do you exercise regularly?
- No
- Yes
If yes, how often and how much
Do you practice stress management techniques?
- No
- Yes
Are you pregnant?
- No
- Yes
Diet: Describe your daily typical food intake:
First Meal*
Second Meal*
Third Meal*
Any Snacks*

Step 4 of 10: Doctor Information
Are you currently under the care of a physician?
- No
- Yes
If yes, please list each doctor from who you seek care, including address and phone.
Doctor Name
Address
Phone #
Doctor Name
Address
Phone #
Doctor Name
Address
Phone #

Step 5 of 10: Snap Caps
I requested my prescription be dispensed in a NON-CHILD PROOF container. ONLY SIGN HERE IF YOU WANT SNAP-CAP CLOSURES ON YOUR PRESCRIPTION CONTAINER.
Signature
Date

Step 6 of 10: Allergies
Please check all that apply
- Penicillin
- Morphine
- Sulfa Drug
- Morphine
- Aspirin
- Food Allergies
- Dye Allergies
- Nitrate Allergy
- Pet Allergies
- Seasonal Allergies
- No known allergies
- Other
If other:
Please describe the allergic reaction you experienced and when it occurred:

Step 7 of 10: Over-the-Counter (OTC) Issues
Indicate which of the following conditions you occasionally or regulary treat with non-prescription (OTC) medications, herbals, vitamin/mineral, or homeopathic remedies:
- Allergy symptoms
- Cough and cold
- Constipation
- Diarrhea
- Weight control/dieting
- Pain
- Eye problems
- Fibromyalgia
- Vaginal problems
- Breathing or nasal problems
- Arthritis
- Heartburn
- Stomach Problems
- Other
Please check all products you are use occasionally or regularly:
- Pain reliever (check all that apply).
- Aspirin
- Acetaminophen (example:Tylenol®)
- Ibuprofen (example:Mortin®)
- Naproxen (example:Aleve®)
- Ketoprofen (example:Orudis®)
- Combination product (cough & cold)
- Sleep aids (example:Excedrin PM®)
- Antidiarrheals (example:Imodium®)
- Laxative/stool softeners (example: Colace®)
- Diet aids/weight loss products
- Antacids (example:Maalox®)
- Cough Suppressants (example:Robitussin®)
- Acid Blockers (example: Tagamet®)
- Antihistamine products (example:Chlor-Trimeton ®)
- Decongestant products (example:Sudafed®)
- Nutritional/Natural Supplements:
Please identify and list the products you are using:
Vitamins (examples: multiple or single vitamins such as B complex, E, C etc.)
Minerals (examples: calcium, magnesium, chromium, colloidal minerals)
Herbs (example: Ginseng, Ginkgo Biloba, Echinacea, medicinal teas etc.)
Enzymes (examples: digestive formulas, papaya, bromelain, CoEnzyme Q12)
Nutrition/protein supplements (examples: shark cartilage, protein pwds)
Other (glucosamine, etc.)

Step 8 of 10: Medical Conditions/Disease
Check all that apply
- Heart Disease (example: Congestive Heart Failure)
- High cholesterol or lipids (example: Hyperlipidermia)
- High Blood Pressure (example: Hypertension)
- Cancer
- Ulcers (stomach, esophagus)
- Throid Disease
- Eye Disease (example: Retinopathy, Glaucoma, Macular Degeneration)
- Lung Condition (example: asthma, emphysema, COPD)
- Diabetes
- Arthritis or joint problems
- Depression
- Epilepsy
- Headaches/migraines
- Other (please list)
If other (please list)

Step 9 of 10: Prescription Medications
Please list all prescription medications you are currently using that were not obtained at this pharmacy. Be sure to include any mail order or physicians samples. We will manually check these against any prescription medications you obtain here for possible interactions.
Doctor Name*
Medication Name*
Date*
How many times per day?*
Doctor Name*
Medication Name*
Date*
How many times per day?*
Doctor Name*
Medication Name*
Date*
How many times per day?*

Step 10 of 10: Hormone Replacement Therapy Patient Information Sheet
Have you experienced any of the following symptoms recently? Please circle the number that best describes your experiences, with one being Extremely Mild and ten being Extremely Severe.
Name*
1. Sleep Disruptions
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
2. Fatigue
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
3. Vaginal Dryness
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
4. Irritability
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
5. Nervousness
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
6. Breast Tenderness
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
7. Hot Flashes
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
8. Dry Skin
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
9. Mood Swings
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
10 Arthritis
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
11.Loss of Recent Memory
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
12.Weight Gain
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
13.Decreased Sex Drive
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
14.Depression
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
15.Fluid Retention
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
16.Headaches
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
17.Night Sweats
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
18.Hair Loss
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
19.Harder to Reach Climax
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
20.Bladder Symptoms
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
21.Cold Hands Hold Feet
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
22.Other
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
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