Initial Consultation - CFPC - CENTER FOR PHARMACEUTICAL COMPOUNDING

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
Treatment Used
Was Treatment Successful?
Describe Problem
Mild/Moderate/Severe
Treatment Used
Was Treatment Successful?
Describe Problem
Mild/Moderate/Severe
Treatment Used
Was Treatment Successful?
Describe Problem
Mild/Moderate/Severe
Treatment Used
Was Treatment Successful?
Describe Problem
Mild/Moderate/Severe
Treatment Used
Was Treatment Successful?
Describe Problem
Mild/Moderate/Severe
Treatment Used
Was Treatment Successful?
Describe Problem
Mild/Moderate/Severe
Treatment Used
Was Treatment Successful?
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?
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?
Were you a premature baby?
Were you a breast fed baby?
Were you a bottle fed baby?
As a child did you eat a lot of sugar and/or candy?
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

Initial Consultation Part 1

Consent & Release Agreement

Consent

Release

PARENT OR GUARDIAN SIGN BELOW, IF APPLICABLE

PERSONAL HISTORY QUESTIONNAIRE

Ongoing Problems

Past Illness, Injury and Surgical History

INJURIES

DIAGNOSTIC STUDIES

OPERATIONS

Hospitalizations

How often have you have taken antibiotics?

How often have you taken oral steroids (e.g., Cortisone, Prednisone, etc.)?

What medications are you taking now?

Childhood

Diet

Meals

Bowel Movements

How well have things been going for you?

Family History

FOR WOMEN ONLY