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Local:
(269) 327-0033
Toll Free:
(877) 774-8757
Fax:
(269) 327-2709
info@centerforcompounds.com
Who We Are
Our Staff
Accreditation
Compounding
Compounding Solutions
RX Refills
Consultation Services
Compounded Hormone Therapy
Foreign Travel & Immunizations
Pain Management
Veterinary Needs
Hospice Needs
CBD
Contact Us
FAQ
Who We Are
Our Staff
Accreditation
Compounding
Compounding Solutions
RX Refills
Consultation Services
Compounded Hormone Therapy
Foreign Travel & Immunizations
Pain Management
Veterinary Needs
Hospice Needs
CBD
Contact Us
FAQ
Initial Consultation
Initial Consultation
Initial Consultation Part 1
Consent & Release Agreement
Name
Date of Birth
MM slash DD slash YYYY
Phone Number
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Email
Consent
Portage Pharmacy (“Pharmacy”) offers consultations with respect to hormonal evaluation, weight management, and nutritional consulting and provides certain related tests (“Services”). A Pharmacy representative has explained to me the nature of the Services I have asked to receive, which are specified in the questionnaire, the goals I hope to achieve with the help of the Pharmacy’s Services, and some of the possible risks.
I understand that making recommendations regarding health matters is not an exact science and that the Pharmacy makes no guarantee that I will be able to achieve the goals I seek or avoid any particular risks. I understand that the Pharmacy is not engaged in the practice of medicine and it is my responsibility to seek the advice of my physician before acting on recommendations provided by the Pharmacy. I understand that the personal and medical history I provide to the Pharmacy and the Pharmacy’s evaluation of my health status is done to help me achieve my individualized goals and is not intended to identify specific health problems I may have and is not a substitute for a physician’s examination. I understand it is my responsibility to provide complete and accurate information to the Pharmacy and to inform the Pharmacy about physical or mental conditions that may affect the Services and that my failure to do so could adversely affect my health, the Pharmacy’s recommendations and my ability to achieve my individualized goals.
The data and/or results derived from the Services are to be considered preliminary only. Test results are in no way conclusive and do not constitute a diagnosis of any medical condition. The responsibility to obtain professional medical assistance and to initiate any follow-up medical care to confirm results of screenings or tests is mine alone, and not that of the Pharmacy or its affiliates. No other person will have access to my personal medical profile and/or test results without my express verbal or written permission. Aggregate data may be used for statistical and research purposes. I voluntarily consent to receive the Services under the terms described in this Agreement.
Release
I voluntarily assume all risks of physical or other problems that may result from the Pharmacy’s Services and I release the Pharmacy, its affiliates and their employees and owners (the “Pharmacy Group”) from all claims, damages, liabilities and expenses (including attorney’s fees and costs) of any kind, including injury or death, arising from or related to the Services provided by the Pharmacy (the “Claims”), known or unknown, that I, or anyone claiming on my behalf, might now or later have as a result of the negligence of any member of the Pharmacy Group and I agree not to sue or otherwise assert any Claims against any member of the Pharmacy Group. I am at least 18 years of age, or if I am under age 18, I understand that I may not receive Services from the Pharmacy unless my parent or guardian signs this Agreement. I HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND ALL MY QUESTIONS WERE ANSWERED TO MY SATISFACTION BEFORE SIGNING THIS AGREEMENT.
Date Signed
MM slash DD slash YYYY
Signature/Initials
Type or Print Name
PARENT OR GUARDIAN SIGN BELOW, IF APPLICABLE
Date Signed
MM slash DD slash YYYY
Signature/Initials
Type or Print Name
PERSONAL HISTORY QUESTIONNAIRE
Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully and accurately to both these written questions and those posed by the Consultant during your consultations. Health issues are usually influenced by many factors. Accurately assessing all the factors and comprehensively managing them is the best way to deal with these health challenges. Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify health and nutritional issues and will assist us in helping you to achieve your individual goals.
First Name
Middle Name
Last Name
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone
Work Phone
Birth Date
MM slash DD slash YYYY
Age
Place of Birth
Occupation
Referred By
Name of Medical Provider
Height
Weight
Sex
Today's Date
MM slash DD slash YYYY
Race
Please Select Appropriate Boxes
African American
Hispanic
Mediterranean
Asian
Native American
Caucasian
Northern European
Other
Ongoing Problems
Please order current and ongoing problems by priority and fill in all fields as completely as possible:
Describe Problem
Mild/Moderate/Severe
Mild
Moderate
Severe
Treatment Used
Was Treatment Successful?
Yes
No
Moderately
Describe Problem
Mild/Moderate/Severe
Mild
Moderate
Severe
Treatment Used
Was Treatment Successful?
Yes
No
Moderately
Describe Problem
Mild/Moderate/Severe
Mild
Moderate
Severe
Treatment Used
Was Treatment Successful?
Yes
No
Moderately
Describe Problem
Mild/Moderate/Severe
Mild
Moderate
Severe
Treatment Used
Was Treatment Successful?
Yes
No
Moderately
Describe Problem
Mild/Moderate/Severe
Mild
Moderate
Severe
Treatment Used
Was Treatment Successful?
Yes
No
Moderately
Describe Problem
Mild/Moderate/Severe
Mild
Moderate
Severe
Treatment Used
Was Treatment Successful?
Yes
No
Moderately
Describe Problem
Mild/Moderate/Severe
Mild
Moderate
Severe
Treatment Used
Was Treatment Successful?
Yes
No
Moderately
With whom do you live
(Include children, parents, relatives, and/or friends and the ages of each individual):
Do you have any pets or farm animals?
Yes
No
Where do they live?
Indoors
Outdoors
Both Indoors/Outdoors
Have you lived or traveled outside of the United States?
Yes
No
Please List When and Where
Have you or your family recently experienced any major life changes?
Yes
No
Please Describe
Have you experienced any major losses in life?
Yes
No
Please Describe
How important is religion (or spirituality) for you and/or your family’s life?
Not Important
Somewhat Important
Extremely Important
How much time have you lost from work or school in the past year?
0-2 days
3-14 days
> 15 days
Please list Previous Jobs
Past Illness, Injury and Surgical History
Anemia
Yes
When
MM slash DD slash YYYY
Comments
Arthritis
Yes
When
MM slash DD slash YYYY
Comments
Asthma
Yes
When
MM slash DD slash YYYY
Comments
Bronchitis
Yes
When
MM slash DD slash YYYY
Comments
Cancer
Yes
When
MM slash DD slash YYYY
Comments
Chronic Fatigue Syndrome
Yes
When
MM slash DD slash YYYY
Comments
Crohn’s Disease or Ulcerative Colitis
Yes
When
MM slash DD slash YYYY
Comments
Diabetes
Yes
When
MM slash DD slash YYYY
Comments
Emphysema
Yes
When
MM slash DD slash YYYY
Comments
Epilepsy, convulsions, or seizures
Yes
When
MM slash DD slash YYYY
Comments
Gallstones
Yes
When
MM slash DD slash YYYY
Comments
Gout
Yes
When
MM slash DD slash YYYY
Comments
Heart attack/Angina
Yes
When
MM slash DD slash YYYY
Comments
Heart failure
Yes
When
MM slash DD slash YYYY
Comments
Hepatitis
Yes
When
MM slash DD slash YYYY
Comments
High blood fats (cholesterol, triglycerides)
Yes
When
MM slash DD slash YYYY
Comments
High blood pressure (hypertension)
Yes
When
MM slash DD slash YYYY
Comments
Irritable bowel
Yes
When
MM slash DD slash YYYY
Comments
Kidney stones
Yes
When
MM slash DD slash YYYY
Comments
Mononucleosis
Yes
When
MM slash DD slash YYYY
Comments
Pneumonia
Yes
When
MM slash DD slash YYYY
Comments
Rheumatic fever
Yes
When
MM slash DD slash YYYY
Comments
Sinusitis
Yes
When
MM slash DD slash YYYY
Comments
Sleep apnea
Yes
When
MM slash DD slash YYYY
Comments
Stroke
Yes
When
MM slash DD slash YYYY
Comments
Thyroid disease
Yes
When
MM slash DD slash YYYY
Comments
Other
Yes
When
MM slash DD slash YYYY
Comments
INJURIES
Back Injury
Yes
When
MM slash DD slash YYYY
Comments
Broken Bones
Yes
When
MM slash DD slash YYYY
Comments
Head injury
Yes
When
MM slash DD slash YYYY
Comments
Neck Injury
Yes
When
MM slash DD slash YYYY
Comments
Other
Yes
When
MM slash DD slash YYYY
Comments
DIAGNOSTIC STUDIES
Barium Enema
Yes
When
MM slash DD slash YYYY
Comments
Bone Scan
Yes
When
MM slash DD slash YYYY
Comments
CAT Scan of Abdomen
Yes
When
MM slash DD slash YYYY
Comments
CAT Scan of Brain
Yes
When
MM slash DD slash YYYY
Comments
CAT Scan of Spine
Yes
When
MM slash DD slash YYYY
Comments
Chest X-ray
Yes
When
MM slash DD slash YYYY
Comments
Colonoscopy
Yes
When
MM slash DD slash YYYY
Comments
EKG
Yes
When
MM slash DD slash YYYY
Comments
Liver scan
Yes
When
MM slash DD slash YYYY
Comments
Neck X-ray
Yes
When
MM slash DD slash YYYY
Comments
NMR/MRI
Yes
When
MM slash DD slash YYYY
Comments
Sigmoidoscopy
Yes
When
MM slash DD slash YYYY
Comments
Upper GI Series
Yes
When
MM slash DD slash YYYY
Comments
Other
Yes
When
MM slash DD slash YYYY
Comments
OPERATIONS
Appendectomy
Yes
When
MM slash DD slash YYYY
Comments
Dental Surgery
Yes
When
MM slash DD slash YYYY
Comments
Gall Bladder
Yes
When
MM slash DD slash YYYY
Comments
Hernia
Yes
When
MM slash DD slash YYYY
Comments
Hysterectomy (Complete or Partial)
Yes
When
MM slash DD slash YYYY
Comments
Tonsillectomy
Yes
When
MM slash DD slash YYYY
Comments
Other
Yes
When
MM slash DD slash YYYY
Comments
Other
Yes
When
MM slash DD slash YYYY
Comments
Hospitalizations
Where Hospitalized?
When?
MM slash DD slash YYYY
Reason?
Where Hospitalized?
When?
MM slash DD slash YYYY
Reason?
Where Hospitalized?
When?
MM slash DD slash YYYY
Reason?
Where Hospitalized?
When?
MM slash DD slash YYYY
Reason?
Where Hospitalized?
When?
MM slash DD slash YYYY
Reason?
How often have you have taken antibiotics?
Infancy/ Childhood
< 5 times
> 5 times
Teen
< 5 times
> 5 times
Adulthood
< 5 times
> 5 times
How often have you taken oral steroids (e.g., Cortisone, Prednisone, etc.)?
Infancy/ Childhood
< 5 times
> 5 times
Teen
< 5 times
> 5 times
Adulthood
< 5 times
> 5 times
What medications are you taking now?
Medication Name
Date Started
MM slash DD slash YYYY
Dosage
Medication Name
Date Started
MM slash DD slash YYYY
Dosage
Medication Name
Date Started
MM slash DD slash YYYY
Dosage
Medication Name
Date Started
MM slash DD slash YYYY
Dosage
Medication Name
Date Started
MM slash DD slash YYYY
Dosage
Medication Name
Date Started
MM slash DD slash YYYY
Dosage
Medication Name
Date Started
MM slash DD slash YYYY
Dosage
Medication Name
Date Started
MM slash DD slash YYYY
Dosage
Are you allergic to any medications?
Yes
No
Please List
List all vitamins, minerals, and other nutritional supplements that you are taking. Please indicate the dosage and how many times per day each supplement is taken:
Vitamin/Mineral/Supplement
Date Started
MM slash DD slash YYYY
Dosage
Vitamin/Mineral/Supplement
Date Started
MM slash DD slash YYYY
Dosage
Vitamin/Mineral/Supplement
Date Started
MM slash DD slash YYYY
Dosage
Vitamin/Mineral/Supplement
Date Started
MM slash DD slash YYYY
Dosage
Vitamin/Mineral/Supplement
Date Started
MM slash DD slash YYYY
Dosage
Vitamin/Mineral/Supplement
Date Started
MM slash DD slash YYYY
Dosage
Vitamin/Mineral/Supplement
Date Started
MM slash DD slash YYYY
Dosage
Vitamin/Mineral/Supplement
Date Started
MM slash DD slash YYYY
Dosage
Childhood
Were you a full term baby?
yes
no
unsure
Were you a premature baby?
yes
no
unsure
Were you a breast fed baby?
yes
no
unsure
Were you a bottle fed baby?
yes
no
unsure
As a child did you eat a lot of sugar and/or candy?
yes
no
unsure
As a child, were there any foods that you had to avoid because they caused symptoms?
Yes
No
Please name the food(s) and symptom(s) below:
Diet
How much of the following do you consume each week?
Candy
Cheese
Chocolate
Cups of caffeinated coffee or tea
Cups of decaffeinated coffee or tea
Cups of hot chocolate
Diet Sodas
Ice Cream
Salty Foods
Slices of white bread (rolls/bagels)
Sodas with caffeine
Sodas without caffeine
Are you on a special diet?
Yes
No
What Kind?
Ovo-Lacto
Vegetarian
Diabetic
Vegan
Dairy Restricted
Blood Type Diet
Is there anything special about your diet that we should know?
Yes
No
Please Explain
Meals
Place a check mark next to the food/drink that applies to your current diet
Usual Breakfast
Check All That Apply
None
Bacon/Sausage
Bagel
Butter
Cereal
Coffee
Donut
Eggs
Fruit
Juice
Margarine
Milk
Oat Bran
Sugar
Sweet Roll
Sweetener
Tea
Toast
Water
Wheat Bran
Yogurt
Usual Lunch
Check All That Apply
None
Butter
Coffee
Eat in a cafeteria
Eat in a restaurant
Fish Sandwich
Juice
Leftovers
Lettuce
Margarine
Mayo
Meat Sandwich
Milk
Salad
Salad Dressing
Soda
Soup
Sugar
Sweetener
Tea
Tomato
Water
Yogurt
Usual Dinner
Check All That Apply
None
Beans (Legumes)
Brown Rice
Butter
Carrots
Coffee
Fish
Green Vegetables
Juice
Margarine
Milk
Pasta
Potato
Poultry
Red Meat
Rice
Salad
Salad Dressing
Soda
Sugar
Sweetener
Tea
Water
Yellow Vegetables
Do you have symptoms immediately after eating (belching, bloating, sneezing, hives, etc?
Yes
No
Please name the food(s) and symptom(s
Do you feel you have delayed symptoms after eating certain foods (symptoms may not be evident for 24 hours or more and may include fatigue, muscle aches, sinus congestion, etc.)
Yes
No
Do you feel worse when you eat:
Check All That Apply
High Fat Foods
High Carbohydrate Foods
Refined Sugar
Alcohol
High Protein Foods
Breads/Pastas/Potatoes
Fried Foods
Other
Please Specify
Do you feel better when you eat:
Check All That Apply
High Fat Foods
High Carbohydrate Foods
Refined Sugar
Alcohol
High Protein Foods
Breads/Pastas/Potatoes
Fried Foods
Other
Please Specify
Does skipping a meal greatly affect your symptoms?
Yes
No
Have you ever had a food that you craved or really "binged" on over a period of time? (food craving may be an indicator that you may be allergic to that food):
Yes
No
Please List
Do you have an aversion to certain foods?
Yes
No
Please List
Bowel Movements
Please select items below with information about your bowel movements:
Frequency
2-3x/day
1x/day
4-6x/week
2-3x/week
1 or fewer/week
Consistency
Soft and well formed
Often float
Difficult to pass
Diarrhea
Thin, long or narrow
Small and hard
Loose but not watery
Alternating between hard and loose/watery
Color
Medium brown consistently
Very dark or black
Greenish color
Blood is visible
Varies a lot
Yellow, light brown
Greasy, shiny appearance
Intestinal Gas
Daily
Present with pain
Occasionally
Foul smelling
Excessive
Little odor
Have you ever used alcohol?
Yes
No
How often do you now drink alcohol?
No longer drinking alcohol
Average 1-3 drinks per week
Average 4-6 drinks per week
Average 7-10 drinks per week
Average >10 drinks per week
Have you ever had a problem with alcohol?
Yes
No
Please indicate time period
MM slash DD slash YYYY
Have you ever used recreational drugs?
Yes
No
Have you ever used tobacco?
Yes
No
Number of years as a nicotine user?
Amount per Day?
Year Quit?
Are you exposed to second hand smoke regularly?
Yes
No
Do you have mercury amalgam fillings?
Yes
No
Do you have any artificial joints or implants?
Yes
No
Do you feel worse at certain times of the year?
Yes
No
When?
Spring
Summer
Fall
Winter
Have you, to your knowledge, been exposed to toxic metals?
Yes
No
Which One?
Lead
Arsenic
Third Choice
Cadmium
Mercury
Aluminum
Do odors affect you?
Yes
No
Please list
How well have things been going for you?
At School
Very Well
Fair
Poor
Very Poor
N/A
In your job
Very Well
Fair
Poor
Very Poor
N/A
In your social life
Very Well
Fair
Poor
Very Poor
N/A
With close friends
Very Well
Fair
Poor
Very Poor
N/A
With sex
Very Well
Fair
Poor
Very Poor
N/A
With your attitude
Very Well
Fair
Poor
Very Poor
N/A
With your boyfriend/girlfriend
Very Well
Fair
Poor
Very Poor
N/A
With your children
Very Well
Fair
Poor
Very Poor
N/A
With your parents
Very Well
Fair
Poor
Very Poor
N/A
With your spouse
Very Well
Fair
Poor
Very Poor
N/A
Have you ever had psychotherapy or counseling?
Yes
No
When?
Currently
Previously
Date
MM slash DD slash YYYY
What kind?
Comments
Are you currently, or have you ever been married?
Yes
No
When were you married?
MM slash DD slash YYYY
Please list your spouse's occupation?
Have you ever been separated?
Yes
No
Never
Have you ever been divorced?
Yes
No
Never
Have you ever been remarried?
Yes
No
Never
Please list your spouses occupation
Comments
Hobbies and leisure activities
Do you exercise regularly
Yes
No
How Often?
1x
2x
3x
4x or more
<15 min
16-30 min
31-45 min
>45 min
Type of exercise?
Jogging/Walking
Basketball
Home Aerobics
Tennis
Water Sports
Family History
Father
Name
Health
Good Health
Poor Health
Deceased
Write in age and cause of death. Include accidents and suicides.
Issues
Alcoholism
Allergies or Asthma
Alzheimer's or Dementia
Anemia
Blood Clotting Problems
Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Heart Trouble
High Blood Pressure
Kidney or Bladder
Nervous Breakdown
Rheumatism or Arthritis
Stomach or ulcer
Mother
Name
Health
Good Health
Poor Health
Deceased
Write in age and cause of death. Include accidents and suicides.
Issues
Alcoholism
Allergies or Asthma
Alzheimer's or Dementia
Anemia
Blood Clotting Problems
Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Heart Trouble
High Blood Pressure
Kidney or Bladder
Nervous Breakdown
Rheumatism or Arthritis
Stomach or ulcer
Brothers/Sisters:
Names
Health
Good Health
Poor Health
Deceased
Write in age and cause of death. Include accidents and suicides.
Issues
Alcoholism
Allergies or Asthma
Alzheimer's or Dementia
Anemia
Blood Clotting Problems
Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Heart Trouble
High Blood Pressure
Kidney or Bladder
Nervous Breakdown
Rheumatism or Arthritis
Stomach or ulcer
Child:
Names
Health
Good Health
Poor Health
Deceased
Write in age and cause of death. Include accidents and suicides.
Issues
Alcoholism
Allergies or Asthma
Alzheimer's or Dementia
Anemia
Blood Clotting Problems
Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Heart Trouble
High Blood Pressure
Kidney or Bladder
Nervous Breakdown
Rheumatism or Arthritis
Stomach or ulcer
Child:
Names
Health
Good Health
Poor Health
Deceased
Write in age and cause of death. Include accidents and suicides.
Issues
Alcoholism
Allergies or Asthma
Alzheimer's or Dementia
Anemia
Blood Clotting Problems
Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Heart Trouble
High Blood Pressure
Kidney or Bladder
Nervous Breakdown
Rheumatism or Arthritis
Stomach or ulcer
Child:
Names
Health
Good Health
Poor Health
Deceased
Write in age and cause of death. Include accidents and suicides.
Issues
Alcoholism
Allergies or Asthma
Alzheimer's or Dementia
Anemia
Blood Clotting Problems
Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Heart Trouble
High Blood Pressure
Kidney or Bladder
Nervous Breakdown
Rheumatism or Arthritis
Stomach or ulcer
Child:
Names
Health
Good Health
Poor Health
Deceased
Write in age and cause of death. Include accidents and suicides.
Issues
Alcoholism
Allergies or Asthma
Alzheimer's or Dementia
Anemia
Blood Clotting Problems
Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Heart Trouble
High Blood Pressure
Kidney or Bladder
Nervous Breakdown
Rheumatism or Arthritis
Stomach or ulcer
Paternal relative:
Names
Health
Good Health
Poor Health
Deceased
Write in age and cause of death. Include accidents and suicides.
Issues
Alcoholism
Allergies or Asthma
Alzheimer's or Dementia
Anemia
Blood Clotting Problems
Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Heart Trouble
High Blood Pressure
Kidney or Bladder
Nervous Breakdown
Rheumatism or Arthritis
Stomach or ulcer
Maternal relative:
Names
Health
Good Health
Poor Health
Deceased
Write in age and cause of death. Include accidents and suicides.
Issues
Alcoholism
Allergies or Asthma
Alzheimer's or Dementia
Anemia
Blood Clotting Problems
Diabetes
Cancer or Tumor
Epilepsy
Genetic Disease
Heart Heart Trouble
High Blood Pressure
Kidney or Bladder
Nervous Breakdown
Rheumatism or Arthritis
Stomach or ulcer
Any other family history we should know about?
Yes
No
Please Describe
What is the attitude of those close to you about your symptoms?
Supportive
Non-Supportive
Please Explain
FOR WOMEN ONLY
Have you ever been pregnant?
Yes
No
Number of term births
Birth weight of largest baby
Birth weight of smallest baby
Were any of your children born premature?
Yes
No
Please Describe
Did you develop any complications with any of your pregnancies?
Yes
No
Please List
Have you ever had any interrupted pregnancies?
Yes
No
Number of miscarriages
Number of Abortions
Other
Age of first cycle?
Date of last Pap Smear?
Date of last Mammogram?
Pap Smear
Normal
Abnormal
Please Comment
Mammogram
Normal
Abnormal
Please Comment
Have you ever used birth control pills?
Yes
No
When?
MM slash DD slash YYYY
Are you taking birth control pills now?
Yes
No
Did taking birth control pills agree with you?
Yes
No
Do you currently use contraception?
Yes
No
Please Describe
Are you in menopause?
Yes
No
Date of Last Cycle
MM slash DD slash YYYY
Please list all hormones you are currently taking or have taken in the past?
How long have you been on hormone therapy? (if applicable)
In the second half of your cycle, do you have symptoms of breast tenderness, water retention, irritability, etc. (PMS)
Yes
No
Not applicable
Please Comment