| Patient Information: Fields marked with an asterisk (*) are required. |
| *First Name: | |
*Last Name: | |
| *Street Address: |
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| Street Line 2: |
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| *City: | |
*State: | *Zip Code: |
| *Phone: |
ext.
Area Prefix Number
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Type of Phone: |
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| Alternate Phone: |
ext.
Area Prefix Number
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| Type of Phone: |
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| *E-mail: |
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*Height:
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*Weight:
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*Gender:
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| Do you use tobacco?
Yes
No
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How often do you use tobacco, what type and how much?
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| Do you use caffeine?
Yes
No
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How often do you use caffeine, what type and how much?
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| Do you exercise regularly?
Yes
No
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Describe what exercises you do and how often.
(aerobic, weight training, running, walkgin, etc.)
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Do you practice any stress management techniques?
Yes
No
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Describe what stress managementtechniques you use and
how often. (yoga, prayer, meditatiojn, etc.)
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Describe your typical first meal?
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Describe your typical second meal?
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Describe your typical third meal?
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Describe any other foods or snacks you eat?
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Are you currently under the care of a physician?
Yes
No
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Current Doctor Name
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Current Doctor Street Address Line 1)
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Current Doctor Street Address (Line 2)
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Current Doctor City
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Current Doctor State and Zip Code
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Current Doctor Phone Number
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Describe any allergies you have.
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Describe any allergic reaction you have experienced and when it occurred.
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Describe any OTC products you use.
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Describe any vitamins you use.
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Describe any minerals you use.
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Describe any herbs you use.
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Describe any enzymes you use.
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What nutritional or protein supplements do you use?
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What other natural or nutritional supplements do you use?
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Medical conditions and when you were diagnosed (list including dates)
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Current Medications, Strengths and how you use them.
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How did you arrive at the decision to consider Rx BHRT?
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What is your bone size?
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| Authorized Physician Name
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Authorized Doctor Street Address Line 1)
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Authorized Doctor Street Address (Line 2)
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Authorized Doctor City
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Authorized Doctor State and Zip Code
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Authorized Doctor Phone Number
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| Pharmacy Record Release Authorization Name
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Pharmacy Record Release Authorization Street Address Line 1)
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Pharmacy Record Release Authorization Street Address (Line 2)
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Pharmacy Record Release Authorization City
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Pharmacy Record Release Authorization State and Zip Code
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Pharmacy Record Release Authorization Phone Number
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Do you have any questions about Rx BHRT??
1)
2)
3)
4)
5)
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