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Pre-Consult Questionnaire

This form must be completed either online or in person before your consultation. To make an appointment for a consultation, please Schedule a Consult or contact us at 1-800-718-3588 extension 110. Your physician's contact information must be completed.

Note: USC does not charge a fee to evaluate this consultation form.

General Patient Information

Name:
Address:
City:
State:
Zip:
Email Address:
Home Phone:
Work Phone:
Gender:
Marital Status:
Birthdate:

Physician Information

Physician Name:
Address:
City:
State:
Zip:
Clinic Phone #:
Fax #:

Personal Health Information

Height:
Weight:
Do you use tobacco?:
Do you drink more than 2 beverages with caffeine daily?:
Check all that apply to you:


Medical Conditions:
List all the current prescription medications you are taking:
List all over-the-counter medications you are taking:
List any drug allergies:
*Check any nutritional / natural supplements:


Family History (please check all that apply):


Family members (from history question):
Which hormones have you previously taken? Please include the date you stopped taking them, the reason you were taking them and why you stopped:
Check all the hormonal symptoms that apply to you:







Lifestyle & Nutrition

Top 3 symptoms you want relieved:
Symptom 1
Symptom 2
Symptom 3
Date of last Pap Smear:
Date of last Mammogram:
How often do you have a bowel movement?:
On average, how many hours of sleep do you get each night?:
Please describe any chronic pain below:
Rate your pain on a scale of 1-10 (1 being the least and 10 the most):
Have you had any chronic stressors? (ex: death in family, divorce, financial crisis):
Additional symptoms/conditions the pharmacist needs to know about:
Describe a typical daily menu:
Breakfast:
Snack:
Lunch:
Snack:
Dinner:

Female Patients

Number of pregnancies you've had:
Has your partner had a vasectomy?:
Any Interrupted Pregnancies?:
Have you had a hysterectomy?:
Have you had ovaries removed?
Have you had a tubal ligation? (aka tubal or had your tubes tied):
When was your last period?:
How long did it last?:
Describe your last period:
Do you have or did you ever have PMS?:
*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: Black Cohosh, Ginseng, Ginkgo Biloba, Echinacea, other herbal medicinal teas, etc.)
Enzymes (examples: digestive formulas, papaya, bromelain, CoEnzyme Q10, etc.)
Nutritional/Protein Supplements (examples: shark cartilage, protein powders, amino acids, fish oils)
Others: (examples: glucosamine, progesterone cream)