|
Establish Care
|
Rescheduled
|
|
Reason for visit
|
Relocated
|
|
General HPI
|
Requesting Past Medical History
|
|
Do you feel safe at home?
|
|
|
Taking Meds?
|
Taking Meds Comments
|
|
Adverse Effects
|
Adverse Effects Comments
|
|
Healthy Diet
|
Healthy Diet Comments
|
|
Regular Exercise
|
Regular Exercise Comments
|
|
Labs done
|
Labs done comments
|
|
Medication Refill Only
|
Lab review only
|
|
Personal Care
|
|
|
LMP
|
Sexual Activity
• • •
|
|
Vaginal symptoms
• • •
|
Breast Changes
|
