Please fill out the form below as instructed by one of our friendly pharmacists.

Name *
Name
Date of Birth *
Date of Birth
Phone *
Phone
Basic Medical Background
(i.e. Amoxicillin Hives/Rash)
(i.e. dyes, pollens, food, etc...)
(i.e. Lipitor 20mg every night)
In Depth Questions
Have you ever had a bone density scan?
Do you use tobacco products?
Do you use alcohol products?
Do you use caffeine products?
Do you use recreational drugs?
When was your last general medical exam?
When was your last pelvic exam?
Have you ever had an abnormal pap smear?
Please indicate the date (approximate) of your last period (LMP).
Please indicate the date (approximate) of your last period (LMP).
Have you experienced difficult, irregular, or abnormal periods?
Have you have ever had Premenstrual Symptoms (PMS)?
If you are experiencing any of the following symptoms please select them below.
Have you experienced any recent unusual vaginal discharge or itching?
Have you had a tubal ligation (tubes tied)?
Have you had a hysterectomy (uterus removal)?
Have you had a oophorectomy (ovary removal)?
Has your doctor diagnosed menopause, or told you that you are in menopause?
Have you ever been pregnant?
For the following symptoms, please rate their impact on your daily life on a scale of 1 to 10, with 1 being no impact at all on your daily life and 10 being severe impact on your daily life.