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Want online portal access?
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If yes, confirm email address
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Who referred you?
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Did you find us online? webpage?
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Do you see any specialists?
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If yes, list them .
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Patient’s Social History
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Currently employed?
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Occupation
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Employer Name
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Highest education
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Marital Status
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Partner's Occupation
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Sexual Orientation
• • •
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Habits
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Tobacco
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If yes, How many pack per day ?
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How many years ?
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Caffeine use?
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If yes, How many cups per day ?
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Alcohol consumption
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How much per week ?
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Drugs
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If yes, What type and how often?
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Hours of sleep ?
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Family History
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Check yes if family unknown:
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Problems Mother had
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Problems Father had
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Grandparents(Maternal/ Paternal)
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Siblings Major illnesses
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Children Major illness
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Describe other:
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Patient Medical History
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Check the problems you've had
• • •
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List hospitalizations
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Past Surgeries
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Describe other:
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Women Only
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Last PAP smear:
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# of Pregnancies
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Last Mammogram
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# of abortions/miscarriage
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# of Children
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How often do you have a period?
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Date your last period began:
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Age when you started periods
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How long do they last?
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Are your periods ?
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# of sex partners in past year:
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