| Date: ____/____/_____ | |
| Name:__________________________________________________________________ Age:_____ | |
| Last Menstrual Period: _____/_____/_____ | |
| Do you have any problems, questions or concerns that you would like to discuss with us today? | |
| ________________________________________________________________________________________ | |
| ________________________________________________________________________________________ | |
| Do you have a family Doctor or Primary Care Doctor? No___ | |
| If yes, what
is his/her name, specialty and location? ________________________________________________________________________________________ |
|
| Have you seen him/her or any other Doctor recently? No___ If yes, for what reason? | |
| ________________________________________________________________________________________ | |
| Have you had any recent illnesses or accidents? No___ If yes, please explain: | |
| ________________________________________________________________________________________ | |
| Has there been a change in your periods? No___ If yes, in what way: | |
| ________________________________________________________________________________________ | |
| Do you currently use any method of birth control? No___ If yes, which type? _________________ | |
| Have you changed your occupation? No___ Yes___ [ Please explain: ] | |
| ________________________________________________________________________________________ | |
| Has there been any change in your relationship with your husband, boyfriend or partner? No___ | |
| If yes, please explain:____________________________________________________________________ | |
| ________________________________________________________________________________________ | |
| Has there been any change in intimacy or sexual desire (libido)? No___ Yes___ | |
| Is this an area that you would like to discuss? No___ Yes___ | |
| Are you taking medications now? No___ If yes, please list them: | |
| 1._______________ 2._______________ 3. _______________ 4. _______________ 5. ______________ | |
| Do you smoke cigarettes? No___ If yes, how many? _______________________________________ | |
| Are you currently exercising? No___ If yes, how often & what type? __________________________ | |
| ________________________________________________________________________________________ | |
| Date of your last mammogram. ____/____/_____ ( if you are over forty ) | |
| Date of your last cholesterol test. ____/____/_____ | |
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