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Marital Status:
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REFERRED BY:
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WHY HAVE YOU COME TO THE OFFICE TODAY?
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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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Health Information
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Date of Last Menstrual Period (FIRST DAY- mmddyyy)
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Ht_____ Ft. ____ In ____ Wt: ____lbs
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Have you been diagnosed with any gynecological problems? If so, please list them.
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Age of first menstrual period.
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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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How many pregnancies have you had?
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How many live births have you had?
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How many misscarriages have you had?
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How many pregnancy terminations have you had?
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Any pregnancy complications?
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Have you ever had any difficulty conceiving?
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Do you have any bleeding between your periods?
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Have you ever had pelvic infections?
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If YES, what type and when?
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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?
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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?
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IF YES, PLEASE INDICATE THE LOCATIONS
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PERSONAL PAST HISTORY OF ILLNESSES
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ASTHMA
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IF YES, PLEASE INDICATE THE DATE
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PNEUMONIA/LUNG DISEASE
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IF YES, PLEASE INDICATE THE DATE
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KIDNEY INFECTIONS/STONES
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IF YES, PLEASE INDICATE THE DATE
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TUBERCULOSIS
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IF YES, PLEASE INDICATE THE DATE
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FIBROIDS
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IF YES, PLEASE INDICATE THE DATE
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SEXUALLY TRANSMITTED DISEASE/CHLAMYDIA
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IF YES, PLEASE INDICATE THE DATE
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INFERTILITY
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IF YES, PLEASE INDICATE THE DATE
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HIV/AIDS
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IF YES, PLEASE INDICATE THE DATE
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HEART ATTACK/DISEASE
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IF YES, PLEASE INDICATE THE DATE
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DIABETES
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IF YES, PLEASE INDICATE THE DATE
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HIGH BLOOD PRESSURE
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IF YES, PLEASE INDICATE THE DATE
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STROKE
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IF YES, PLEASE INDICATE THE DATE
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RHEUMATIC FEVER
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IF YES, PLEASE INDICATE THE DATE
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BLOOD CLOTS IN LUNGS OR LEGS
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IF YES, PLEASE INDICATE THE DATE
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EATING DISORDERS
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IF YES, PLEASE INDICATE THE DATE
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AUTOIMMUNE DISEASE (LUPUS)
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IF YES, PLEASE INDICATE THE DATE
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CHICKENPOX
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IF YES, PLEASE INDICATE THE DATE
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CANCER
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IF YES, PLEASE INDICATE THE DATE
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REFLUX/HIATAL HERNIA/ULCERS
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IF YES, PLEASE INDICATE THE DATE
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DEPRESSION/ANXIETY
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IF YES, PLEASE INDICATE THE DATE
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ANEMIA
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IF YES, PLEASE INDICATE THE DATE
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BLOOD TRANSFUSIONS
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IF YES, PLEASE INDICATE THE DATE
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SEIZURES/CONVULSIONS EPILEPSY
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IF YES, PLEASE INDICATE THE DATE
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BOWEL PROBLEMS
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IF YES, PLEASE INDICATE THE DATE
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GLAUCOMA
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IF YES, PLEASE INDICATE THE DATE
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CATARACTS
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IF YES, PLEASE INDICATE THE DATE
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ARTHRITIS/JOINT PAIN/BACK PROBLEMS
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IF YES, PLEASE INDICATE THE DATE
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BROKEN BONES
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IF YES, PLEASE INDICATE THE DATE
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HEPATITIS/YELLOW JAUNDICE/LIVER DISEASE
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IF YES, PLEASE INDICATE THE DATE
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GALLBLADDER DISEASE
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IF YES, PLEASE INDICATE THE DATE
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HEADACHES
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IF YES, PLEASE INDICATE THE DATE
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DES EXPOSURE
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IF YES, PLEASE INDICATE THE DATE
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INFERTILITY
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IF YES, PLEASE INDICATE THE DATE
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BLEEDING DISORDER
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IF YES, PLEASE INDICATE THE DATE
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OTHER
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OPERATIONS/HOSPITALIZATIONS
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REASON
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DATE
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HOSPITAL
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REASON
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DATE
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HOSPITAL
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INJURIES/ILLNESSES
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TYPE
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DATE
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TYPE
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DATE
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TYPE
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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
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Please select if any of the following symptoms apply to you now or since adulthood
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1. CONSTITUTIONAL
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WEIGHT LOSS
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COMMENT
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WEIGHT GAIN
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COMMENT
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FEVER
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COMMENT
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FATIGUE
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COMMENT
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CHANGE IN HEIGHT
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COMMENT
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2. EYES
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DOUBLE VISION
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COMMENT
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SPOTS BEFORE EYES
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COMMENT
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VISION CHANGES
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COMMENT
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GLASSES/ CONTACTS
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COMMENT
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3. EAR, NOSE, AND THROAT
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EARACHES
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COMMENT
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RINGING IN EARS
|
COMMENT
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HEARING PROBLEMS
|
COMMENT
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SINUS PROBLEMS
|
COMMENT
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SORE THROAT
|
COMMENT
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MOUTH SORE
|
COMMENT
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DENTAL PROBLEMS
|
COMMENT
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4. CARDIOVASCULAR
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CHEST PAIN OR PRESSURE
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COMMENT
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DIFFICULTY BREATHING ON EXERTION
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COMMENT
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SWELLlNG OF LEGS
|
COMMENT
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RAPID OR IRREGULAR HEARTBEAT
|
COMMENT
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5. RESPIRATORY
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PAINFUL BREATHING
|
COMMENT
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WHEEZING
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COMMENT
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SPITTING UP BLOOD
|
COMMENT
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SHORTNESS OF BREATH
|
COMMENT
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CHRONIC COUGH
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COMMENT
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6. GASTROINTESTINAL
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FREQUENT DIARRHEA
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COMMENT
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BLOODY STOOL
|
COMMENT
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NAUSEA/VOMITING/INDIGESTION
|
COMMENT
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CONSTIPATION
|
COMMENT
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INVOLUNTARY LOSS OF GAS OR STOOL
|
COMMENT
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7. GENITOURINARY
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BLOOD IN URINE
|
COMMENT
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PAIN WITH URINATION
|
COMMENT
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STRONG URGENCY TO URINATE
|
COMMENT
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FREQUENT URINATION
|
COMMENT
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INCOMPLETE EMPTYING
|
COMMENT
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INVOLUNTARY/UNINTENDED URINE LOSS
|
COMMENT
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URINE LOSS WHEN COUGHING OR LIFTING
|
COMMENT
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ABNORMAL BLEEDING
|
COMMENT
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PAINFUL PERIODS
|
COMMENT
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PREMENSTRUAL SYNDROME (PMS)
|
COMMENT
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PAINFUL INTERCOURSE
|
COMMENT
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ABNORMAL VAGINAL DISCHARGE
|
COMMENT
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8. MUSCULOSKELETAL
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MUSCLE WEAKNESS
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COMMENT
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MUSCLE OR JOINT PAIN
|
COMMENT
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9. SKIN
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MOLES (GROWTH OR CHANGES)
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COMMENT
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10. BREASTS
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PAIN IN BREAST
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COMMENT
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NIPPLE DISCHARGE
|
COMMENT
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LUMPS
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COMMENT
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11. NEUROLOGIC
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DIZZINESS
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COMMENT
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SEIZURES
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COMMENT
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NUMBNESS
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COMMENT
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TROUBLE WALKING
|
COMMENT
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MEMORY PROBLEMS
|
COMMENT
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FREQUENT HEADACHES
|
COMMENT
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12. PSYCHIATRIC
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DEPRESSION OR FREQUENT CRYING
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COMMENT
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ANXIETY
|
COMMENT
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SEXUAL HEALTH CONCERNS
|
COMMENT
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13. ENDOCRINE
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HAIR LOSS
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COMMENT
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HEAT/COLD INTOLERANCE
|
COMMENT
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ABNORMAL THIRST
|
COMMENT
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HOT FLASHES
|
COMMENT
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14. HEMATOLOGIC/LYMPHATIC
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FREQUENT BRUISES
|
COMMENT
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CUTS DO NOT STOP BLEEDING
|
COMMENT
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ENLARGED LYMPH NODES (GLANDS)
|
COMMENT
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15. ALLERGIC/IMMUNOLOGIC
|
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MEDICATION ALLERGIES
|
COMMENT
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|
IF ANY, PLEASE LIST ALLERGY AND TYPE OF REACTION
|
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LATEX ALLERGY
|
COMMENT
|
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OTHER ALLERGIES
|
COMMENT
|
|
PLEASE LIST ALLERGY AND TYPE OF REACTION
|
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|
FORM COMPLETED BY:
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