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Date: ____/____/_____ Name:________________________________________________________________ Last First M.I. Age:_________ Email: _________________@___________________ |
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| What brings you to our office today? | |
| _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ |
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| Do you have any problems or concerns that you would like to discuss with us today? | |
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___Vaginal discharge/ itching ___Involuntary loss of urine ___Bleeding ___Hot flashes/ menopause symptoms |
___Sexual problems ___Cramps ___Other |
| Past Medical History | |
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___Hypertension ___Diabetes ___Heart Problems ___Cancer ___Hepatitis ___Phlebitis or Blood Clots ___Transfusions |
___Asthma ___Thyroid Disease ___Migraines ___Seizures ___Gastro-intestinal Problems ___Fractures ___Anemia ___Bladder / Kidney Problems |
| Surgical History (please list all operations and dates) | |
| 1._____________________________________________________________
2._____________________________________________________________ 3._____________________________________________________________ 4._____________________________________________________________ 5. _____________________________________________________________ |
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Social History |
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___Smoke ___Drink ______________Marital Status Exercise ___No ___Yes Type & Frequency: |
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| 1.
_____________________________________________________________ 2. _____________________________________________________________ 3. _____________________________________________________________ 4. _____________________________________________________________ 5. _____________________________________________________________ |
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Current Drugs and Medications (including non-prescription medicines, vitamins, Natural products, etc.) |
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| 1.
_____________________________________________________________ 2. _____________________________________________________________ 3. _____________________________________________________________ 4. _____________________________________________________________ 5. _____________________________________________________________ |
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Allergies (to drugs and medications) |
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| 1.
_____________________________________________________________ 2. _____________________________________________________________ 3. _____________________________________________________________ 4. _____________________________________________________________ 5. _____________________________________________________________ |
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| Family History | |
| Mother
living? ___Yes ___No _____Current age/Age at Death |
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| Father
living? ___Yes ___No _____Current age/Age at Death |
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| List any family members with a history of the following disorders: | |
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___Heart Attack ___Breast Cancer ___Stroke ___Ovarian Cancer ___Diabetes |
___Uterine Cancer ___Hypertension ___Colon Cancer ___Prostate Cancer ___Other Cancers |
| GYN HISTORY | |
| _____/_____/______ First day of your last menstrual period: | |
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________Age at first menstruation ________Length of periods (total bleeding days): |
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| Do
you have regular periods? ___Yes ___No Usual Interval: ______ days |
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| Cramps? ___None ___Mild ___Moderate ___Severe | |
| Flow: ___Light ___Medium ___Heavy ___Clots | |
| Do you suffer from PMS or mood changes each month? ___No ___Yes ___Help! | |
| Contraception History | |
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Have you ever used? (Check all that apply): ___Pill ___Diaphragm ___Condom ___Injections (Depo-Provera) |
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| Have
you ever had a problem with any form of contraception? ___No ___Yes If yes, which type and why: |
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| _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ |
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| Present method of contraception: If you are using a pill, which one? | |
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_______________________________________________________________ |
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| Have
you ever taken Estrogen (hormone) Replacement? ___No ___Yes If yes, what did you take? |
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| _______________________________________________________________ |
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| If you are currently taking any hormones (including Natural products), please list them. | |
| 1._____________________________________________________________
2._____________________________________________________________ 3._____________________________________________________________ 4._____________________________________________________________ 5. _____________________________________________________________ |
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| OBSTETRICAL HISTORY | |
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___Total pregnancies ___Number of living children ___Full term pregnancies |
___Miscarriages ___Abortions ___Pregnancy complications |
| ____/____/_____ Last pelvic exam | ____/____/_____ Last Pap Smear |
| ____/____/_____ Last mammogram | ____/____/_____ Last blood work up |
| Name of other Physicians you currently see or have seen in the past 5 years . | |
| 1._____________________________________________________________
2._____________________________________________________________ 3._____________________________________________________________ 4._____________________________________________________________ 5. _____________________________________________________________ |
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