T.W.U. Institute for Women's Health Pioneer Project

Year 1 Medical History Questionnaire
Personal Medical History

Section 5: Medication History

 
Hormone Usage
 
32. Have you ever used female hormones (other than oral contraceptives)? YES    NO (Skip to question 33)
 
32.1 Are you currently using hormones (within the last month)? YES    NO
 
32.2 What is the longest amount of time you used hormones consecutively?
 
32.3 What type of hormone have you used the longest during this time period?
Oral Premarin or conjugated estrogen alone
Oral progesterone (e.g. Provera) alone
Oral conjugated estrogen and progesterone
patch estrogen and oral progesterone
 Patch estrogen alone
Vaginal estrogen
Depo-Prevera (injections)
Other (specify)   
 
32.4 If you used oral conjugated estrogen (e.g. Premarin) what dose did you usually take?
 
32.5 If you used oral Progesterone, what dose did you usually take?
 
32.6 What was your pattern of hormone use (days per month)?
Oral or Patch Estrogen:
Progesterone:
 
33. Please indicate below any medication (if any) you have taken by marking the box to the left of the name of the medication. If you have NOT taken any of the medications, please do not check any of the boxes.
Date Last Taken (Month/Year)
Antidepressants (Prozac, Elavil, etc.) -
Antiestrogen (Tamoxifen) -
Estrogen -
Oral Contraceptives (Birth control pills) -
Progestin or progesterone -
Depo-Provera (injections) -
Norplant -
Other hormone(s) (specify)    -
Calcium supplements -
 
34. Please list any other PRESCRIPTION medications you are currently taking that have not been described in questions 32 or 33.
Medication Dose Date Start
(month/year)		 Reason
-
-
-
-
 
If you need additional space, please use the box below:

35. Please list all NON-PRESCRIPTION medication or vitamins or nutritional supplements you are currently taking.
Medication Dose Date Start
(month/year)		 Reason
-
-
-
-
-
-
 
If you need additional space, please use the box below: