Female Consultation Form InstagramThis field is for validation purposes and should be left unchanged.Are You Currently a Florida Resident?(Required) Yes, I am a Florida Resident.Today's Date(Required) MM slash DD slash YYYY Personal InformationName(Required) First Last Are you a current patient of Barclay's Apothecary Shoppe?(Required) Yes No Date of Birth(Required) MM slash DD slash YYYY Age(Required)Height(Required)Weight(Required)Address(Required) Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Phone(Required)Work PhoneOccupationPrimary Physician(Required)Primary Physician Phone(Required)Secondary PhysicianSecondary Physician PhoneWhat is your greatest need or problem? (List the most important; then list other issues in order of importance):(Required) N/A Other Please enter information hereYour current medical conditions or diagnoses:(Required) N/A Other Please enter information hereDrug allergies:(Required) N/A Other Please enter information hereAllergies to food, pollens, environment, etc:(Required) N/A Other Please enter information hereNames of ALL prescription medications, taken in last 6 months. Include strength and how you take them:(Required) N/A Other Please enter information hereIndicate any herbal products you have taken: (Evening Primrose Oil (EPO), Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc):(Required) N/A Other Please enter information hereNames of ALL Vitamins, Supplements, Non-prescription medicines, or other OTC products that you are currently using:(Required) N/A Other Please enter information hereIf you are you currently taking medication for a thyroid condition, which one and dose?(Required) N/A Other Please enter information hereHave you ever had a bone density scan?(Required) Yes No Date MM slash DD slash YYYY ResultsDo you use tobacco products?(Required) Yes No What?For how long?Do you use alcohol products?(Required) Yes No What?How much?For how long?Do you use caffeine products?(Required) Yes No What?How much?Do you use recreational drugs?(Required) Yes No What?How much?How much water do you drink in one day (24 hr)?(Required)Glasses / Ounces Glasses Ounces Is your drinking water from(Required) City Water Distilled Water Bottled Water Water Purifier Dietary Restrictions (such as salt, carbohydrates, milk products, red meat, etc):(Required) N/A Other Please enter information hereFamily History: List Important DiseasesMotherMother Living / Deceased Living Deceased FatherFather Living / Deceased Living Deceased BrothersBrothers Living / Deceased Living Deceased SistersSisters Living / Deceased Living Deceased AuntsAunts Living / Deceased Living Deceased UnclesUncles Living / Deceased Living Deceased Paternal GrandmaPaternal Grandma Living / Deceased Living Deceased Paternal GrandpaPaternal Grandpa Living / Deceased Living Deceased Maternal GrandmaMaternal Grandma Living / Deceased Living Deceased Maternal GrandmaMaternal Grandma Living / Deceased Living Deceased When was your last general medical exam:(Required) MM slash DD slash YYYY When was your last pelvic exam: MM slash DD slash YYYY Have you ever had an abnormal Pap?(Required) Yes No When? MM slash DD slash YYYY TreatmentAt what age was your First Period (menarche)?(Required)When was your most recent or last period (LMP):(Required) MM slash DD slash YYYY Do you still have your period?(Required) Yes No How many days from the start of one period to the start of the next?(Required)Number of days of flow:(Required)Amount of bleeding:Describe any cramping or pain you may have:(Required)Do you have pain at any other time in your cycle?(Required) Yes No Where, when, how long?Any current changes in your normal cycle?(Required)Any bleeding between periods (IMB):(Required) Yes No When and describe:What were your periods like as a teenager?(Required)Have you have ever had Premenstrual Symptoms (PMS), please describe:(Required)How long have you had PMS symptoms?(Required)Starting and ending when:If your periods have ever been difficult, irregular, or abnormal in any way, please describe:If you are you currently having any pelvic pain, pressure, or fullness, describe:Describe any recent unusual vaginal discharge or itching:Treatment for any of above:Have you had any of the following surgeries?Tubes tied (tubal ligation)?(Required) Yes No When? MM slash DD slash YYYY At what age?Uterus removed (hysterectomy)?(Required) Yes No When? MM slash DD slash YYYY Why?Ovaries removed (oophorectomy)?(Required) Yes No Part If Yes or PART, What?When? MM slash DD slash YYYY Why?Were there any problems associated with the surgery or removal of any of these organs?Has your doctor diagnosed menopause, or told you that you are in menopause?(Required) Yes No If Yes, at what age?If at age 40 years or earlier, was Premature Ovarian Failure, diagnosed? Yes No Have you ever been pregnant?(Required) Yes No Are you trying to get pregnant?(Required) Yes No What was your age at your first pregnancy?How many times have you been pregnant (gravida)?(Required)How many pregnancies resulted in the birth of living children (para)?Were there any problems?Any interrupted pregnancies (miscarriages or abortions)?Current birth control method:How long:Any problems?Have you ever used any of the following birth control methods:Oral Contraceptives (Birth Control Pills)(Required) Yes No Total months/years used:Describe any side effects to Birth Control Pills:Intra-Uterine Device (IUD)(Required) Yes No Problems?When was your last mammogram? MM slash DD slash YYYY Results:Do you examine your breasts monthly?(Required) Yes No Have you ever experienced breast pain, discomfort, nipple discharge, or swelling other than when pregnant? Give details:Have you ever been diagnosed with lumps, fibroids, breast cancer, or similar breast conditions?If your doctor has recently ordered lab tests or diagnostic procedures for you, please give details, including whether the test or procedure was performed, and the results:Symptoms CHECK A BOX FOR EACH SYMPTOM which best describes how you have been feeling for the past 3 weeks. 0 = None (symptom not present) 1 = Mild (present but not distressing) 2 = Moderate (distressing, but not interfering with daily life) 3 = Severe (very distressing, interferes with daily life) If you wish to add comments or details, please send by separate email to our pharmacy, indicating your first and last name in the email. Thank you. Hot flashes(Required) 0 1 2 3 Night sweats(Required) 0 1 2 3 Light-headed feelings/dizziness(Required) 0 1 2 3 Headaches(Required) 0 1 2 3 Sleep disorders/Sleeplessness(Required) 0 1 2 3 Unusual tiredness/Fatigue(Required) 0 1 2 3 Irritability(Required) 0 1 2 3 Depression(Required) 0 1 2 3 Anxiety/Tension/Nervousness(Required) 0 1 2 3 Mood swings/Mood changes(Required) 0 1 2 3 Confusion/Difficulty concentrating(Required) 0 1 2 3 Forgetfulness/Short-term memory loss(Required) 0 1 2 3 Angry outbursts/Arguments/Violent tendencies(Required) 0 1 2 3 Crying easily(Required) 0 1 2 3 Backache(Required) 0 1 2 3 Joint pains(Required) 0 1 2 3 Muscle pains(Required) 0 1 2 3 Muscle cramps/spasms(Required) 0 1 2 3 Problems with wound healing time(Required) 0 1 2 3 Acne/Pimples/Skin flushing(Required) 0 1 2 3 New facial hair(Required) 0 1 2 3 Dry skin/Dry hair(Required) 0 1 2 3 Crawling feeling under skin(Required) 0 1 2 3 Frequent Urinary Tract Infection (UTI)(Required) 0 1 2 3 Urinary frequency(Required) 0 1 2 3 Vaginal dryness(Required) 0 1 2 3 Abnormal bleeding(Required) 0 1 2 3 Pelvic pain, pressure, fullness, or bloating(Required) 0 1 2 3 Uncomfortable intercourse(Required) 0 1 2 3 Loss of sexual feeling/desire(Required) 0 1 2 3 Loss of arousability & capacity for orgasm(Required) 0 1 2 3 Loss of vitality(Required) 0 1 2 3 Nipple sensitivity(Required) 0 1 2 3 Discharge or leaking from nipples(Required) 0 1 2 3 Breast tenderness(Required) 0 1 2 3 Loss of pubic hair(Required) 0 1 2 3 Swelling of hands, ankles, or breasts(Required) 0 1 2 3 Heart palpitations(Required) 0 1 2 3 Shortness of breath(Required) 0 1 2 3 Food /sweets /salt cravings(Required) 0 1 2 3 Increased appetite/weight gain(Required) 0 1 2 3 Visual disturbance or decreased vision(Required) 0 1 2 3 Difficulty hearing(Required) 0 1 2 3 Diminished sense of taste(Required) 0 1 2 3 Diminished sense of smell(Required) 0 1 2 3 Schedule ConsultationPlease select 3 times that work best for a phone consultation with one of our pharmacists. Our times offered are Monday - Friday with time blocks from 9:00am-12:00pm, 12:00pm-3:00pm or 3:00pm-6:00pm. Consults typically last between 30 minutes and one hour. We will check availability and get back with you with a specific time.Date(Required) MM slash DD slash YYYY Time Block(Required)First Time Block Requested9:00am-12:00pm12:00pm-3:00pm3:00pm-6:00pmDate(Required) MM slash DD slash YYYY Time Block(Required)Second Time Block Requested9:00am-12:00pm12:00pm-3:00pm3:00pm-6:00pmDate(Required) MM slash DD slash YYYY Time Block(Required)Third Time Block Requested9:00am-12:00pm12:00pm-3:00pm3:00pm-6:00pmAttention Patients: Important Update! If you don't receive a "SUCCESS" message upon submission, please make sure all required fields have been completed and resubmit.
