Marital Status:
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NAME Of SPOUSE/PARTNER:
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REFERRED BY:
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WHY HAVE YOU COME TO THE OFFICE TODAY?
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IS THIS A NEW PROBLEM?
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PLEASE DESCRIBE YOUR PROBLEM, INCLUDING WHERE IT IS AND HOW LONG IT HAS LASTED.
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SEVERITY OUT OF 10
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If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse.
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GYNECOLOGIC HISTORY
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LAST NORMAL MENSTRUAL PERIOD (FIRST DAY- mmddyyy)
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AGE PERIODS BEGAN
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LENGTH OF PERIODS (NUMBER OF DAYS OF BLEEDING)
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NUMBER OF DAYS BETWEEN PERIODS:
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ANY RECENT CHANGES IN PERIODS?
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If YES, Please provide changes here
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ARE YOU CURRENTLY SEXUALLY ACTIVE?
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Comments
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HAVE YOU EVER HAD SEX?
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Comments
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NUMBER Of SEXUAL PARTNERS (LIFETIME)
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SEXUAL PARTNERS ARE
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PRESENT METHOD OF BIRTH CONTROL:
• • •
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If other, please specify here
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HAVE YOU EVER USED AN INTRAUTERINE DEVICE (IUD) OR BIRTH CONTROL PILLS?
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IF YES, FOR HOW LONG?
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WHEN WAS YOUR LAST PAP TEST? ?(MM/DD/YYYY)
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HAVE YOU EVER HAD AN ABNORMAL PAP TEST?
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WHAT WAS THE RESULT?
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DO YOU DO BREAST SELF-EXAMINATIONS?
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HAVE YOU BEEN EXPOSED TO DIETHYLSTILBESTROL (DES)?
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SEXUAL HEALTH HISTORY
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In the past, was your level of sexual desire or interest good and satisfying for you?
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Has there been a decrease in your level of sexual desire or interest?
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Are you bothered by your decreased level of sexual desire or interest?
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Would you like your level of sexual desire or interest to increase?
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Please select all the factors that you feel may be contributing to your current decrease in sexual desire or interest.
• • •
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OBSTETRIC HISTORY
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PREGNANCIES
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PREM ATURE BIRTHS (<37 WEEKS)
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ABORTIONS
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LIVE BIRTHS
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MISCARRIAGES
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LIVING CHlLDREN
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Please complete answering based on the # of pregnancies
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PREGNANCY #1
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PREGNANCY #2
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PREGNANCY #3
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PREGNANCY #4
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BIRTH DATE (mmddyyyy)
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WEIGHT AT BIRTH
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BABY'S SEX
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WEEK'S PREGNANT
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TYPE OF DELIVERY
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ANY PREGNANCY COMPLlCATIONS?
• • •
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IF YOU SELECTED OTHER, PLEASE SPECIFY HERE
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ANY HISTORY OF DEPRESSION BEFORE OR AFTER PREGNANCY?
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IF YES, HOW WAS IT TREATED?
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BIRTH DATE (mmddyyyy)
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WEIGHT AT BIRTH
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BABY'S SEX
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WEEK'S PREGNANT
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TYPE OF DELIVERY
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ANY PREGNANCY COMPLlCATIONS?
• • •
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IF YOU SELECTED OTHER, PLEASE SPECIFY HERE
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ANY HISTORY OF DEPRESSION BEFORE OR AFTER PREGNANCY?
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IF YES, HOW WAS IT TREATED?
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BIRTH DATE (mmddyyyy)
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WEIGHT AT BIRTH
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BABY'S SEX
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WEEK'S PREGNANT
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TYPE OF DELIVERY
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ANY PREGNANCY COMPLlCATIONS?
• • •
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IF YOU SELECTED OTHER, PLEASE SPECIFY HERE
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ANY HISTORY OF DEPRESSION BEFORE OR AFTER PREGNANCY?
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IF YES, HOW WAS IT TREATED?
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BIRTH DATE (mmddyyyy)
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WEIGHT AT BIRTH
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BABY'S SEX
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WEEK'S PREGNANT
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TYPE OF DELIVERY
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ANY PREGNANCY COMPLlCATIONS?
• • •
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IF YOU SELECTED OTHER, PLEASE SPECIFY HERE
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ANY HISTORY OF DEPRESSION BEFORE OR AFTER PREGNANCY?
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IF YES, HOW WAS IT TREATED?
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CURRENT MEDICATIONS
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(Including hormones, vitamins, herbs, nonprescription medications)
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DRUG NAME (1)
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DRUG NAME (2)
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DRUG NAME (3)
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DRUG NAME (4)
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DRUG NAME (5)
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DRUG NAME (6)
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DRUG NAME:
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DOSAGE
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WHO PRESCRIBED
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DRUG NAME:
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DOSAGE
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WHO PRESCRIBED
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DRUG NAME:
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DOSAGE
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WHO PRESCRIBED
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DRUG NAME:
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DOSAGE
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WHO PRESCRIBED
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DRUG NAME:
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DOSAGE
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WHO PRESCRIBED
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DRUG NAME:
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DRUG NAME:
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WHO PRESCRIBED
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FAMILY HISTORY
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MOTHER
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IF DECEASED, PLEASE INDICATE CAUSE HERE
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AGE
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FATHER
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IF DECEASED, PLEASE INDICATE CAUSE HERE
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AGE
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SIBLINGS: NUMBER LIVING
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SIBLINGS: NUMBER DECEASED
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CAUSES:
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AGE
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CHILDREN: NUMBER LIVING
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CHILDREN: NUMBER DECEASED
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CAUSES:
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AGE
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FAMILY ILLNESS
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DIABETES
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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STROKE
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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HEART DISEASE
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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BLOOD CLOTS IN LUNGS OR LEGS
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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HIGH BLOOD PRESSURE
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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HIGH CHOLESTEROL
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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OSTEOPOROSIS (WEAK BONES)
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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HEPATITIS
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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HIV/AIDS
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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TUBERCULOSIS
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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BIRTH DEFECTS
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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ALCOHOL OR DRUG PROBLEMS
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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BREAST CANCER
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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COLON CANCER
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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OVARIAN CANCER
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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UTERINE CANCER
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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MENTAL lLLNESS/ DEPRESSION
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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ALZHEIMER'S DISEASE
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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OTHER ILLNESS:
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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SOCIAL HISTORY
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EVER SMOKED?
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CURRENTLY SMOKING _____ PACKS PER DAY
/
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IF YES, HOW MANY YEARS?
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ALCOHOL
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TYPE OF DRINK
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DRINKS PER DAY
/
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DRINKS PER WEEK
/
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DRUG USE
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SEAT BELT USE
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REGULAR EXERCISE
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IF YES, HOW LONG AND HOW OFTEN
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DAIRY PRODUCT INTAKE AND/OR CALCIUM SUPPLEMENTS
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DAILY INTAKE :
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HEALTH HAZARDS AT HOME OR WORK?
|
HAVE YOU BEEN SEXUALLY ABUSED, THREATENED, OR HURT BY ANYONE?
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DO YOU HAVE AN ADVANCED DIRECTIVE (LIVING WILL)?
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PERSONAL PROFILE
|
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SEXUAL ORIENTATION:
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MARITAL STATUS:
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NUMBER OF LIVING CHILDREN
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TRAVEL OUTSIDE THE UNITED STATES?
|
IF YES, PLEASE INDICATE THE LOCATIONS
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PERSONAL PAST HISTORY OF ILLNESSES
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ASTHMA
|
IF YES, PLEASE INDICATE THE DATE
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PNEUMONIA/LUNG DISEASE
|
IF YES, PLEASE INDICATE THE DATE
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KIDNEY INFECTIONS/STONES
|
IF YES, PLEASE INDICATE THE DATE
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TUBERCULOSIS
|
IF YES, PLEASE INDICATE THE DATE
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FIBROIDS
|
IF YES, PLEASE INDICATE THE DATE
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SEXUALLY TRANSMITTED DISEASE/CHLAMYDIA
|
IF YES, PLEASE INDICATE THE DATE
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INFERTILITY
|
IF YES, PLEASE INDICATE THE DATE
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HIV/AIDS
|
IF YES, PLEASE INDICATE THE DATE
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HEART ATTACK/DISEASE
|
IF YES, PLEASE INDICATE THE DATE
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DIABETES
|
IF YES, PLEASE INDICATE THE DATE
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HIGH BLOOD PRESSURE
|
IF YES, PLEASE INDICATE THE DATE
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STROKE
|
IF YES, PLEASE INDICATE THE DATE
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RHEUMATIC FEVER
|
IF YES, PLEASE INDICATE THE DATE
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BLOOD CLOTS IN LUNGS OR LEGS
|
IF YES, PLEASE INDICATE THE DATE
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EATING DISORDERS
|
IF YES, PLEASE INDICATE THE DATE
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AUTOIMMUNE DISEASE (LUPUS)
|
IF YES, PLEASE INDICATE THE DATE
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CHICKENPOX
|
IF YES, PLEASE INDICATE THE DATE
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CANCER
|
IF YES, PLEASE INDICATE THE DATE
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REFLUX/HIATAL HERNIA/ULCERS
|
IF YES, PLEASE INDICATE THE DATE
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DEPRESSION/ANXIETY
|
IF YES, PLEASE INDICATE THE DATE
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ANEMIA
|
IF YES, PLEASE INDICATE THE DATE
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BLOOD TRANSFUSIONS
|
IF YES, PLEASE INDICATE THE DATE
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SEIZURES/CONVULSIONS EPILEPSY
|
IF YES, PLEASE INDICATE THE DATE
|
BOWEL PROBLEMS
|
IF YES, PLEASE INDICATE THE DATE
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GLAUCOMA
|
IF YES, PLEASE INDICATE THE DATE
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CATARACTS
|
IF YES, PLEASE INDICATE THE DATE
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ARTHRITIS/JOINT PAIN/BACK PROBLEMS
|
IF YES, PLEASE INDICATE THE DATE
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BROKEN BONES
|
IF YES, PLEASE INDICATE THE DATE
|
HEPATITIS/YELLOW JAUNDICE/LIVER DISEASE
|
IF YES, PLEASE INDICATE THE DATE
|
GALLBLADDER DISEASE
|
IF YES, PLEASE INDICATE THE DATE
|
HEADACHES
|
IF YES, PLEASE INDICATE THE DATE
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DES EXPOSURE
|
IF YES, PLEASE INDICATE THE DATE
|
INFERTILITY
|
IF YES, PLEASE INDICATE THE DATE
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BLEEDING DISORDER
|
IF YES, PLEASE INDICATE THE DATE
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OTHER
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OPERATIONS/HOSPITALIZATIONS
|
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REASON
|
DATE
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HOSPITAL
|
|
REASON
|
DATE
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HOSPITAL
|
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INJURIES/ILLNESSES
|
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TYPE
|
DATE
|
TYPE
|
DATE
|
TYPE
|
DATE
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IMMUNIZATIONS/TESTS
|
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TETANUS - DIPHTHERIA BOOSTER/Date
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HEPATITIS A VACCINE/Date
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VARICELLA (CHICKENPOX) VACCINE/Date
|
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MEASLES-MUMPS-RUBELLA (MMR) VACCINE/Date
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INFLUENZA VACCINE (FLU SHOT)/Date
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HEPATITIS B VACCINE/Date
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PNEUMOCOCCAL (PNEUMONIA) VACCINE/Date
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TUBERCULOSIS (TB)SKIN TEST RESULT:/Date
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REVIEW OF SYSTEMS
|
|
Please select if any of the following symptoms apply to you now or since adulthood
|
|
1. CONSTITUTIONAL
|
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WEIGHT LOSS
|
COMMENT
|
WEIGHT GAIN
|
COMMENT
|
FEVER
|
COMMENT
|
FATIGUE
|
COMMENT
|
CHANGE IN HEIGHT
|
COMMENT
|
2. EYES
|
|
DOUBLE VISION
|
COMMENT
|
SPOTS BEFORE EYES
|
COMMENT
|
VISION CHANGES
|
COMMENT
|
GLASSES/ CONTACTS
|
COMMENT
|
3. EAR, NOSE, AND THROAT
|
|
EARACHES
|
COMMENT
|
RINGING IN EARS
|
COMMENT
|
HEARING PROBLEMS
|
COMMENT
|
SINUS PROBLEMS
|
COMMENT
|
SORE THROAT
|
COMMENT
|
MOUTH SORE
|
COMMENT
|
DENTAL PROBLEMS
|
COMMENT
|
4. CARDIOVASCULAR
|
|
CHEST PAIN OR PRESSURE
|
COMMENT
|
DIFFICULTY BREATHING ON EXERTION
|
COMMENT
|
SWELLlNG OF LEGS
|
COMMENT
|
RAPID OR IRREGULAR HEARTBEAT
|
COMMENT
|
5. RESPIRATORY
|
|
PAINFUL BREATHING
|
COMMENT
|
WHEEZING
|
COMMENT
|
SPITTING UP BLOOD
|
COMMENT
|
SHORTNESS OF BREATH
|
COMMENT
|
CHRONIC COUGH
|
COMMENT
|
6. GASTROINTESTINAL
|
|
FREQUENT DIARRHEA
|
COMMENT
|
BLOODY STOOL
|
COMMENT
|
NAUSEA/VOMITING/INDIGESTION
|
COMMENT
|
CONSTIPATION
|
COMMENT
|
INVOLUNTARY LOSS OF GAS OR STOOL
|
COMMENT
|
7. GENITOURINARY
|
|
BLOOD IN URINE
|
COMMENT
|
PAIN WITH URINATION
|
COMMENT
|
STRONG URGENCY TO URINATE
|
COMMENT
|
FREQUENT URINATION
|
COMMENT
|
INCOMPLETE EMPTYING
|
COMMENT
|
INVOLUNTARY/UNINTENDED URINE LOSS
|
COMMENT
|
URINE LOSS WHEN COUGHING OR LIFTING
|
COMMENT
|
ABNORMAL BLEEDING
|
COMMENT
|
PAINFUL PERIODS
|
COMMENT
|
PREMENSTRUAL SYNDROME (PMS)
|
COMMENT
|
PAINFUL INTERCOURSE
|
COMMENT
|
ABNORMAL VAGINAL DISCHARGE
|
COMMENT
|
8. MUSCULOSKELETAL
|
|
MUSCLE WEAKNESS
|
COMMENT
|
MUSCLE OR JOINT PAIN
|
COMMENT
|
9. SKIN
|
|
MOLES (GROWTH OR CHANGES)
|
COMMENT
|
10. BREASTS
|
|
PAIN IN BREAST
|
COMMENT
|
NIPPLE DISCHARGE
|
COMMENT
|
LUMPS
|
COMMENT
|
11. NEUROLOGIC
|
|
DIZZINESS
|
COMMENT
|
SEIZURES
|
COMMENT
|
NUMBNESS
|
COMMENT
|
TROUBLE WALKING
|
COMMENT
|
MEMORY PROBLEMS
|
COMMENT
|
FREQUENT HEADACHES
|
COMMENT
|
12. PSYCHIATRIC
|
|
DEPRESSION OR FREQUENT CRYING
|
COMMENT
|
ANXIETY
|
COMMENT
|
SEXUAL HEALTH CONCERNS
|
COMMENT
|
13. ENDOCRINE
|
|
HAIR LOSS
|
COMMENT
|
HEAT/COLD INTOLERANCE
|
COMMENT
|
ABNORMAL THIRST
|
COMMENT
|
HOT FLASHES
|
COMMENT
|
14. HEMATOLOGIC/LYMPHATIC
|
|
FREQUENT BRUISES
|
COMMENT
|
CUTS DO NOT STOP BLEEDING
|
COMMENT
|
ENLARGED LYMPH NODES (GLANDS)
|
COMMENT
|
15. ALLERGIC/IMMUNOLOGIC
|
|
MEDICATION ALLERGIES
|
COMMENT
|
IF ANY, PLEASE LIST ALLERGY AND TYPE OF REACTION
|
|
LATEX ALLERGY
|
COMMENT
|
OTHER ALLERGIES
|
COMMENT
|
PLEASE LIST ALLERGY AND TYPE OF REACTION
|
|
FORM COMPLETED BY:
|
|