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.

Multiform1

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

Step 2 of 10: Patient Information

Gender

Step 3 of 10: Lifestyle Information

Do you use

Tobacco (smoke, chew, dip)

Alcohol (beer, wine, hard liquor)

Caffeine (cola, drinks, tea, coffee)

Impairments ( check all that apply )

Do you exercise regularly?

Do you practice stress management techniques?

Are you pregnant?

Diet: Describe your daily typical food intake:

Step 4 of 10: Doctor Information

Are you currently under the care of a physician?

If yes, please list each doctor from who you seek care, including address and 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.

Step 6 of 10: Allergies

Please check all that apply

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:

Please check all products you are use occasionally or regularly:

Please identify and list the products you are using:

Step 8 of 10: Medical Conditions/Disease

Check all that apply

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.

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.

1. Sleep Disruptions
2. Fatigue
3. Vaginal Dryness
4. Irritability
5. Nervousness
6. Breast Tenderness
7. Hot Flashes
8. Dry Skin
9. Mood Swings
10 Arthritis
11.Loss of Recent Memory
12.Weight Gain
13.Decreased Sex Drive
14.Depression
15.Fluid Retention
16.Headaches
17.Night Sweats
18.Hair Loss
19.Harder to Reach Climax
20.Bladder Symptoms
21.Cold Hands Hold Feet
22.Other