Women’s Health Evaluation

Evaluation Form

  • Bedford Wellness Pharmacy
    CONFIDENTIAL WOMEN’S HEALTH & HORMONE EVALUATION

    7473 Secor Rd.
    Lambertville, MI 48144

    The purpose of this evaluation & consultation is to gather information to help your doctor and pharmacist improve your health naturally by restoring hormone balance, optimizing your diet, supplementing with appropriate nutritional products, adopting an active lifestyle, avoiding environmental toxins, and using bio-identical hormones, where appropriate. It is important to note that attaining optimal health is dependent on providing honest, accurate information. Your responses will be held in strictest confidentiality. They are considered protected health information and, as such, are subject to HIPAA privacy laws.

  • Medical History

  • (This is the doctor to whom you would like us to send the recommendation)
  • DIET & LIFESTYLE

  • *Please keep a detailed diary of your diet for 1 week prior to your consultation. You should not change your diet during this time. Bring this to your consultation.
  • Family History

    List family members who have had the following conditions
  • Current Prescription Medications (including current hormones)

  • List Hormones previously taken (including birth control)

  • ** Over-the-counter (OTC) product notice **: Bring these items to your consultation. Please bring all items, whether taken regularly or just occasionally, including (but not limited to) vitamins, supplements, herbal remedies, homeopathic preparations, cold & cough products, antacids, bowel products, pain relievers.
  • OB/GYN History

  • (Per day, per week, or per month)
  • Please list the dates of your last exam(s):

  • Symptoms Checklist

    (including hair loss)