BHRT | Economy Drug (870) 423-2094 | Berryville, AR

There is a new way to pay called Nimble!
When you call in your refill, you will get a text message from them. This will allow you to pay using your cell phone. Nimble is a faster and easier way to refill your prescriptions with the ability to track them if they are mailed to you.
So give Nimble a try, we think you will like it!

Bio-Identical Hormone Replacement Therapy Evaluation

We would love the opportunity to serve as your trusted prescription provider.
Please fill out the form below and we will take it from here!

First Name

Last Name

Address

City

State

Zip Code

Email Address

Phone Number

Birth Date (XX/XX/XXXX)

Gender

Weight

Height

Do you use tobacco?

Yes No

How often and how much?

Do you use alcohol?

Yes No

How often and how much?

Do you use caffeine?

Yes No

How often and how much?

Doctor's Name

Practice Address

Practice Phone Number

Doctor's Name

Practice Address

Practice Phone Number

Doctor's Name

Practice Address

Practice Phone Number

Doctor's Name

Practice Address

Practice Phone Number

Allergies: Please check all that apply.

Penicillin

Codeine

Sulfa Drug

Morphine

Aspirin

Food Allergies

Dye Allergies

Nitrate Allergy

No Allergy

Pet Allergy

Seasonal Allergy

Other Allergy

Please describe the allergic reaction you experienced and when it occurred:

Over-the-counter (OTC) issues:
Please check all products that you use occasionally or regularly. Check all that apply.

Pain Reliever

Aspirin

Acetaminophen (example: Tylenol®)

Ibuprofen (example: Motrin IB®)

Naproxen (example: Aleve®)

Ketoprofen (example: Orudis KT®)

Cough suppressant (example: Robitussin DM®)

Antihistamine product (example: Chlor-Trimeton®)

Decongestant product (example: Sudafed ®)

Combination product (cough+cold reliever)(example: Triaminic DM®)

Sleep aids (exmples: Excedrin PC®, Unisom®, Sominex®, Nytol®)

Antidiarrheals (examples:Imodium®, Pepto Bismol®, Kaopectate®)

Laxatives/stool softeners (examples: Doxidan®, Correctol®, etc.)

Diet aids/weight loss products (example: Dexatril®)

Antacids (examples: Maalox®, Mylanta®)

Acid blockers (examples: Tagamet HB®, Pepcid C®, Zantac 75®)

Others (Please list)

Nutritional/Natural Supplements: Please identify and list the products you are using:

Vitamins (examples: multiple or single vitamins such as B complex, E, C, beta carotene)

Minerals (examples: calcium, magnesium, chromium, colloidal minerals, various single minerals)

Herbs (examples: Ginseng, Ginkgo Biloba, Echinacea, other herbal medicinal teas, tinctures, remedies, etc.)

Enzymes (examples: digestive formulas, papaya, bromelain, CoEnzyme Q10, etc.)

Nutrition/protein supplements (examples: shark cartilage, protein powers, amino acids, fish oils, etc.)

Others (glucosamine, etc.)

Medical Conditions/Diseases: Please check all that apply to you.

Heart disease (example: Congestive Heart Failure)

High cholesterol or lipids (examples: Hyperlipidemia)

High blood pressure (example: Hypertension)

Lung condition (example: asthma, emphysema, COPD)

Ulcers (stomach, esophagus)

Thyroid disease

Hormonal Related Issues

Cancer

Blood Clotting Problems

Diabetes

Arthritis or joint problems

Depression

Epilepsy

Headaches/migraines

Eye Disease (glaucoma, etc.)

Others (Please list)

Current Prescription Medications:

Medication Name

Strength:

Date Started:

How often per day:

Medication Name

Strength:

Date Started:

How often per day:

Medication Name

Strength:

Date Started:

How often per day:

Medication Name

Strength:

Date Started:

How often per day:

Medication Name

Strength:

Date Started:

How often per day:

Medication Name

Strength:

Date Started:

How often per day:

List Hormones previously taken:

Hormone Name

Strength:

Date Started:

How often per day:

Hormone Name

Strength:

Date Started:

How often per day:

Hormone Name

Strength:

Date Started:

How often per day:

Hormone Name

Strength:

Date Started:

How often per day:

Bone Size:

Small Medium Large

Body Type:

Androgenic Estrogenic

Have you ever used oral contraceptives?

Yes No

Any problems?

Yes No

If YES, describe any problem(s).

How many pregnancies have you had?

How many children?

Any interrupted pregnancies?

Yes No

Ovaries Removed?

Yes No

Have you had a hysterectomy?

Yes No

Date of Surgery

Have you had a tubal ligation?

Yes No

Date of Surgery

Do you have a family history of any of the following?

Uterine Cancer

Family member(s)

Ovarian Cancer

Family member(s)

Fibrocystic breast

Family member(s)

Breast Cancer

Family member(s)

Heart Disease

Family member(s)

Osteoporosis

Family member(s)

Have you had any of the following tests performed? Check those that apply and note date of last test.

Mammography

Yes No

Date of Surgery

PAP Smear

Yes No

Date of Surgery

Since you first began having periods, have you ever had what YOU would consider to be abnormal cycles?

Yes No

Date

If YES, please explain (such as age when this occurred, symptoms...):

When was your last period?

How many days did it last?

Do you have, or did you ever have Premenstrual Syndrome (PMS)?

Yes No

If YES, please explain symptoms:

How did you arrive at the decision to consider Bio-Identical Hormone Replacement Therapy?

Doctor Self Friend/Family Member Other

What are your goals with taking BHRT?

Please rate the following symptoms:

Fibrocystic Breast

Absent Mild Moderate Severe

Weight Gain

Absent Mild Moderate Severe

Heavy/Irregular menses

Absent Mild Moderate Severe

Hot Flashes

Absent Mild Moderate Severe

Dry Skin/Hair

Absent Mild Moderate Severe

Anxiety

Absent Mild Moderate Severe

Depression

Absent Mild Moderate Severe

Night Sweats

Absent Mild Moderate Severe

Vaginal Dryness

Absent Mild Moderate Severe

Headaches

Absent Mild Moderate Severe

Irritability

Absent Mild Moderate Severe

Mood Swings

Absent Mild Moderate Severe

Breast Tenderness

Absent Mild Moderate Severe

Sleep Disturbances/Insomnia

Absent Mild Moderate Severe

Cramps

Absent Mild Moderate Severe

Fluid Retention

Absent Mild Moderate Severe

Breakthrough Bleeding

Absent Mild Moderate Severe

Fatigue

Absent Mild Moderate Severe

Loss of Memory

Absent Mild Moderate Severe

Bladder Symptoms

Absent Mild Moderate Severe

Arthritis

Absent Mild Moderate Severe

Harder to Reach Climax

Absent Mild Moderate Severe

Decreased Sex Drive

Absent Mild Moderate Severe

Hair Loss

Absent Mild Moderate Severe

Please write down any questions you have about Bio-Identical Hormone Replacement Therapy.