|
Other complementary practitioners
|
Specialists
|
|
Medical Records Reviewed
|
|
|
PMH
|
Comments.
|
|
Blood Type
|
History of head injury
|
|
Antecedent
|
Birth History
|
|
Previous Genetic Testing
|
Genetic comments
|
|
PSH
|
Comments
|
|
Procedures
|
Comments:
|
|
Imaging studies
|
Comments.
|
|
Cardiology Studies
|
Results
|
|
Medical Records Reviewed
|
Summary of records
|
|
Mold Lab History
|
VCS +
|
|
PREVENTATIVE
|
|
|
Preventative
|
|
|
Last mammogram:
|
Bone Density
|
|
Date of last colonoscopy.
|
EGD
|
|
|
Comment
|
|
Vaccines UTD
|
Vaccines comment
|
|
GYN HISTORY
|
|
|
GYN HX
|
Abnormal Pap
|
|
|
Pap smear comment
|
|
Hysterectomy
|
Ovariectomy
|
|
Menarche age/quality
|
Menopause age /explain
|
|
Hormone Status? (lifetime ocp? HRT?)
|
Comment
|
|
OB HX
|
|
|
Obstetric History
/
|
Age at first child
|
|
Birth Weights of babies (lb/oz)
/
|
New Field
|
|
birth weight 2
/
|
New Field
|
|
birth weight 3
/
|
New Field
|
|
birth weight 4
/
|
New Field
|
|
Other birth weight
|
|
|
FAMILY HISTORY
|
Mother (other)
|
|
Mother
|
Father
|
|
Maternal Grandparents
|
Paternal Grandparents
|
|
Maternal Aunts and Uncles
|
Paternal Aunts and Uncles
|
|
Cousins
|
Cousins
|
|
Sibling Medical History
|
Children
|
|
Any Relatives With >10 Colon/Gastric Polyps
|
Is patient adopted
|
|
Other
|
|
|
LEGAL
|
|
|
Durable Power of Attorney/Living Will info
|
DNR status
|
