Female Symptoms Checklist Template (Page 2 of 2) in pdf

Female Symptoms Checklist Template Page 2

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

Female Symptoms Checklist Template Page 2