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Preferred Pharmacy Name
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Address
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Telephone
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Reason for visit
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Last Menstrual Period (First Day)
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AGE PERIOD BEGAN
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LENGTH OF PERIOD
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HOW OFTEN
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ABNORMAL/IRREGULAR PERIODS
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INFERTILITY/AMENORRHEA
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PAINFUL?
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DATE OF LAST PAP SMEAR
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RESULTS
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HISTORY OF ABNORMAL PAP?
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WHEN
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RESULT
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CURRENT METHOD OF BIRTH CONTROL
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CONDOMS?
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HAVE YOU USED ANY OF THE FOLLOWING (CIRCLE ALL THAT APPLY)
• • •
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HAVE YOU RECEIVED THE VACCINE FOR HPV?
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IF SO, DATES REC'D
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HISTORY OF THE FOLLOWING
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COLPOSCOPY
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(PLEASE PROVIDE DATE WHERE INDICATED)
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LASER SURGERY
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(PLEASE PROVIDE DATE WHERE INDICATED)
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CRYOSURGERY
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(PLEASE PROVIDE DATE WHERE INDICATED)
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LEEP/CONE BIOPSY
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(PLEASE PROVIDE DATE WHERE INDICATED)
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SEXUALLY TRANSMITTED DISEASES (SELECT ALL THAT APPLY):
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SELECT ALL THAT APPLY
• • •
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HAVE YOU EVER BEEN TESTED FOR HIV?
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IF YES, LAST RESULTS
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HISTORY OF THE FOLLOWING
• • •
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GYN CANCER (please specify Ovarian/Cervical/Endometrial/Vaginal/Vulvar)
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EVER BEEN PREGNANT?
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NUMBER OF VAGINAL DELIVERIES
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NUMBER OF C-SECTIONS
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PRETERM?
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COMPLICATIONS
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NUMBER OF MISCARRIAGES
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NUMBER OF ABORTIONS
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NUMBER OF ECTOPIC PREGNANCIES
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TREATED WITH SUGERY OR MEDICATIONS?
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DO YOU PERFORM SELF BREAST EXAMS?
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LAST MAMMOGRAM
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MAMMOGRAM RESULTS:
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BREAST DISCHARGE
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BREAST DISEASE:
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Sexual History (This section is optional and could be deferred for private discussion)
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SEX WITH
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PAIN WITH SEX
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BLEEDING AFTER SEX
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ARE THERE THINGS ABOUT SEX THAT YOU WOULD LIKE TO ASK ABOUT OR DISCUSS?
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MEDICAL HISTORY
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SELECT ALL THAT APPLY
• • •
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***ALLERGIES****
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CURRENT MEDICATIONS (INCLUDING HORMONES/VITAMINS/HERBS)
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SURGICAL HISTORY:
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HAVE YOU HAD SURGERY OF ANY KIND?
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PERSONAL HISTORY:
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EXERCISE (TYPE)
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FREQUENCY
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DURATION
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PLEASE DESCRIBE YOUR DIET
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CURRENT OR PAST USE OF THE FOLLOWING
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CAFFEINE (COFFEE/TEA/SODA)
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CIGARETTES PER DAY
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DRUG USE
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ALCOHOL INTAKE
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FAMILY HISTORY
|
SELECT ALL THAT APPLY
• • •
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YOU and YOUR FAMILY's Cancer History (Please be as thorough and accurate as possible)
|
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Breast cancer
|
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You age of diagnosis
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Parents/Siblings/Children
|
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Age of diagnosis
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Relatives on your mother's side
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Age of diagnosis
|
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Relatives on your father's side
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Age of diagnosis
|
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Ovarian cancer (Peritoneal/Fallopian tube)
|
You age of diagnosis
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Parents/Siblings/Children
|
Age of diagnosis
|
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Relatives on your mother's side
|
Age of diagnosis
|
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Relatives on your father's side
|
Age of diagnosis
|
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Uterine/Endometrial cancer
|
You age of diagnosis
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Parents/Siblings/Children
|
Age of diagnosis
|
|
Relatives on your mother's side
|
Age of diagnosis
|
|
Relatives on your father's side
|
Age of diagnosis
|
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Colon/Rectal cancer
|
You age of diagnosis
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|
Parents/Siblings/Children
|
Age of diagnosis
|
|
Relatives on your mother's side
|
Age of diagnosis
|
|
Relatives on your father's side
|
Age of diagnosis
|
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10 or more lifetime colon polyps
|
Specify #
|
|
You age of diagnosis
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Parents/Siblings/Children
|
|
Age of diagnosis
|
Relatives on your mother's side
|
|
Age of diagnosis
|
Relatives on your father's side
|
|
Age of diagnosis
|
Other cancer(s)
|
|
Specify cancer type
|
You age of diagnosis
|
|
Parents/Siblings/Children
|
Age of diagnosis
|
|
Relatives on your mother's side
|
Age of diagnosis
|
|
Relatives on your father's side
|
Age of diagnosis
|
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Are you of Ashkenazi Jewish descent
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Are you concerned about your personal and/or family history of cancer
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Have you or anyone in your family had genetic testing for a hereditary cancer(Please explain/include a copy of result if possib
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Hereditary Cancer Red Flags (To be completed with your healthcare provider)
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Your personal history - Red flags
|
Hereditary breast and ovarian cancer syndrome
• • •
|
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Lynch syndrome**
• • •
|
Your family history - Red flags
|
|
Hereditary breast and ovarian cancer syndrome
• • •
|
|
|
Lynch syndrome**
• • •
|
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