| 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 ) | ||
| Dat of you last cholesterol test. ____/____/_____ | ||