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Want online portal access?
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If yes, confirm email address
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Do you see any specialists?
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If yes, list them
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Do you have a primary care provider?
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If yes, list them
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Are you being treated for any current medical condition?
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If yes list them (separate with comma if more than one)
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Switch on for WOMEN ONLY questions
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Do you have regular periods?
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Are you going through menopause?
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Are you trying to become pregnant?
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Have you ever been pregnant?
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Are you pregnant or lactating?
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Social History
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Currently employed?
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Employer Name
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Occupation
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Marital Status
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Tobacco
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If yes type and how much?
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Caffeine use?
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If yes, how much?
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Drug use
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If yes, what type and how often?
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Alcohol consumption
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Medical History
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History of sleep apnea?
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Prostate exam in last 12 months? (men only)
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History of cardiac disorder/event:
• • •
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Date(s)
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Type
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Past medical history
• • •
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Additional comments
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Past surgical history
• • •
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Additional comments/surgeries
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Family History
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Father's MH
• • •
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Comments
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Mother's MH
• • •
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Comments
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Sibling(s)' MH
• • •
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Comments
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Grandparent's MH
• • •
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Comments
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Children(s)' MH
• • •
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Comments
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