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This form is for our new patients. When you make your first appointment with us, a welcome packet will be sent to you. In this packet are two information forms that are necessary to create your chart. If you did not receive the medical information form in the mail, we have provided it here for you to print and complete prior to your office visit. |
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MEDICAL INFORMATION ON-LINE NAME _____________________________________________________________________________ Do your currently have any medical problems? ____________________________________________ Do you have any drug allergies? ________________________________________________________ Do You Smoke? _______________________ If so, how much? _______________________________ Do you drink alcohol? _________________ If so, how much? _________________________________ Have you ever been hospitalized and reason? _____________________________________________ GYNECOLOGIC INFORMATION Age of first menstruation? _______________ Are your periods regular? ________________________ Interval between periods ________________ Duration of periods? _____________________________ Any other discomforts associated with your periods? _______________________________________ Do you have any problems with pelvic pain or discomfort with sexual relations? __________________ ___________________________________________________________________________________ Have you ever used birth control pills or any type of hormonal therapy? _________________________ ___________________________________________________________________________________ Any Complications with birth control pills or hormonal therapy? _______________________________ ___________________________________________________________________________________ Have you ever used an IUD? ______________ Any problems? _______________________________ Have you ever had any problems with infertility? ___________________________________________ Have you ever had Gonorrhea, Chlamydia, Herpes, or Condyloma? ____________________________ Please describe any prior Gynecological surgery: __________________________________________ ___________________________________________________________________________________ OBSTETRIC HISTORY How many times have you been pregnant? ______________ Have you had any complications with your pregnancies? ___________________________________________________________________________________ Any miscarriages or bleeding episodes? _________________________________________________ Are there any birth defects or genetic disorders that could run in your extended family? ___________ ___________________________________________________________________________________ Please check or circle any of the following that apply to your family or your husband’s family:
Have you suffered from any of the following medical disorders? Heart Disease Any Family History of the following: Heart Disease Please use the remainder of the page to describe any current problem or topic you wish to discuss with the physician/nurse practitioner: |