Wheelock Pharmacy
Now, 2 locations to better serve you!

Telephone
517.263.7175

Fax:
517.263.0876

Address
700 East Church St.
Adrian, MI 49221

Telephone
517-263-2400

Fax:
517-263-9840

Address
1325 N. Main St.
Adrian, MI 49221
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Date: 03/10/10 3:33:15 PM


* What is Bone size?
Small
When measuring your wrist your fingers overlap
Medium
Fingers meet
Large
Space between fingers
* What is Body type?
Androgenic
Small buttocks
Estrogenic
Pear shape(hips & legs)

Your Details:
First Name: Last Name:
Telephone:  
 Email:
  (123-456-7890)    
About Your History:
   
How did you arrive at the decision to take natural hormones?  Doctors   Self   Friend
   
*Bone Size?   Small   Medium   Large
*Body Type?   Androgenic   Estrogenic
   
Age?    
Have you had any children? Yes No
 
Have you had a hysterectomy? Yes No
If so, how many?  
What Are your current Symptoms?
   
Is there a family history of
Uterine cancer? Yes   No
Ovarian cancer? Yes   No
Breast cancer? Yes   No
Osteoporosis? Yes   No
Heart Disease? Yes   No
Were you prematurely gray?
  Yes   No
   
As a teenager, were your periods normal?
  Yes   No
Did you have PMS?
  Yes   No
Did you have spasmodic dysmenorrghea?
  Yes   No
   
What medications are you currently taking?
Are you currently taking hormones?
  Yes   No
If so, what is your regimen?
Are you taking any vitamins, natural products? (E.g. iron, melatonin, ginseng)
  Yes   No
If so, what and how often? 

Have you experienced any of the following symptoms recently?
Symptoms Yes No Symptoms Yes No
Sleep disruption Loss of recent memory
Fatigue Weight gain
Vaginal dryness Decreased sex drive
Irritability Depression
Nervousness Fluid retention
Breast tenderness Headaches
Hot flashes Night sweats
Dry skin Hair loss
Difficulty concentrating Harder to reach a climax
Arthritis Bladder symptoms






EXPLANATIONS
* Bone size: Small = When measuring your wrist your fingers overlap
  Medium = Fingers meet
  Large = Space between fingers
       
* Body type: Androgenic = Small buttocks
  Estrogenic = Pear shape(hips & legs)




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