SYMPTOMS CHECKLIST DATE: ______/ ______/ ______

Lack of Progesterone Lack of Estrogen

Headache Hot Flashes Low Libido Shortness of Breath Anxiety Night Sweats Swollen Breasts Sleep Disorders Moodiness Vaginal Dryness Fuzzy Thinking Dry Skin Depression Anxiety Food Cravings Mood Swings Irritability Headache Insomnia Depression Cramps Memory Loss Emotional Swings Heart Palpitations Painful Breasts Yeast Infections Weight Gain Vaginal Shrinkage Bloating Painful Intercourse Inability to Concentrate Hair Loss/Dry Hair Asthma Inability to Reach Orgasm Early Menstruation Lack of Menstruation Painful Joints Acne Abundance of Estrogen Excess of Progesterone Water Retention Depression Fatigue Somnolence (Sleepiness) Breast Swelling Fibrocystic Breasts Lack of Testosterone Premenstrual-like Mood Loss of Sex Drive Low Libido/Sex Drive Heavy/irregular Menses Low Energy Uterine Fibroids Loss of Muscle Tone Craving for Sweets Weight Gain

Pitt Street Pharmacy 111 Pitt Street, Mt. Pleasant, SC 29464 p: 843 884 4051 f: 843 884 9117

Pertinent History

Date of Birth _____ /_____ /_____ Any drug allergies? If so, list:______Are you Lactose intolerant, or have trouble digesting milk, dairy products? Any family history of: Breast cancer Cervical/Vaginal cancer Other types of cancer ______Still having periods? ______Regular/Normal? ______Irregular/Abnormal?______Date of last period: _____ / _____ Are you taking/or have you taken any Prescription or Over-the-Counter hormone replacement meds? ______If so, list name and strength of Medication:______

Who is the Doctor you want us to contact for your prescription? ______

Return or Fax: Pitt Street Pharmacy 111 Pitt Street Mt. Pleasant, SC sc 29464 (843) 884 4051 phone (843) 884 9117 fax

Please print: Name: ______Address: ______City: ______ST/Zip: ______Day Time Phone: (____) ______Home Phone: (____) ______Email: ______

Pitt Street Pharmacy 111 Pitt Street, Mt. Pleasant, SC 29464 p: 843 884 4051 f: 843 884 9117