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Intake Form
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Medical Condition History:
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Do you have any other disease, condition or problem not listed above that you feel we should know about? If so, please explain.
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If you currently have or have ever been diagnosed with cancer in the past, please list the type(s) of cancer here:
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Have you had any surgery in the past? If yes, please describe the type and date of the surgery:
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Gyn History
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Last mammogram date (MM/YYYY) and result (Normal or Abnormal)
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HPI
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When was your last pap smear. Date (MM/YYYY) and result?
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Do you have any history of previous abnormal PAP?
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When was your last DEXA scan (Bone Density Test) Date (MM/YYYY) and results, please describe:
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When was your last colonoscopy? Date (MM/YYYY) and treatment:
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Past Medical History
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Is there a history of colon cancer? Date (MM/YYYY) and treatment:
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Is there a history of colon polyps? Date (MM/YYYY) and results:
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Father (Please select all that applies):
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Mother (Please select all that applies):
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Household:
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Marital Status:
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Tobacco Use:
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Alcohol Screen (Audit-C)
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Did you have a drink containing alcohol in the past year?
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Drugs
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Have you used drugs other than for those medical reasons in the past 12 months?
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Caffeine
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On average, how much caffeine do you consume each day?
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Sexual History
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Had sex in the past 12 months (vaginal, oral, or anal)?
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Have you ever had a sexually transmitted disease?
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Sexual History
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Current birth control method?
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Female Only Questions:
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Menstrual History
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Age at first period (in years):
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How many days does your period lasts?
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Gyn History
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Do you have pain with your period?
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Pregnancy History
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Number of pregnancies:
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Full-term deliveries
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Premature deliveries
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Twin deliveries
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Miscarriages
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Terminations
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Total living children
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Gyn History: Do you have infertility issues?
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How often do you exercise?
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Occupation
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General / Constitutional
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Fatigue
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Fever
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Headache
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Lightheadedness
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Weight Gain
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Weight Loss
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Gastrointestinal
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Nausea
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Vomiting
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Gynecology
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Menstrual Irregularities
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Painful Cramps
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HPI
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Is there a documented history of positive TB test or TB disease:
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Do you have prolonged cough, coughing up blood, fever, night sweats, weight loss, or excessive fatigue:
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Do you have any history of close contact to someone with infectious TB disease during lifetime:
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Were you born, travelled or lived in a country with an elevated Tuberculosis rate for at least 1 month.
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Include countries other than the US, Canada, Australia, New Zealand, or Western and North European countries:
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