Breast implants Breast reduction surgery Breast biopsy Breast lumpectomy Chest reconstruction Other:
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1 New Patient Intake Form This form lets us get to know you and know how we can help. Not every question is important to everyone, but the more you can answer, the more we can help. If there is a question that makes you uncomfortable, skip it and discuss it during your visit. Thank you. Do you need help with this form? If you answered yes, please stop filling out the form and speak with a Front Desk staff member. Person filling out this form (if not the patient): Name Relationship to Patient Reason for your visit today: Routine exam Something is bothering me/i have something specific to discuss What medical problems do you have now or have you had in the past? Diabetes High Blood Pressure/hypertension High cholesterol Hepatitis A Hepatitis B Hepatitis C Other liver problems Pancreatitis Kidney failure Cancer Depression or anxiety Thyroid problems Migraines Blood clots Breast disease Allergies Asthma COPD or Emphysema Tuberculosis (TB) HIV or AIDS Addiction to: Other: What operations have you had in the past? Appendix removed Tonsils removed Gall bladder removed Hernia repaired Uterus removed (hysterectomy) Ovaries removed (oophorectomy) Breast implants Breast reduction surgery Breast biopsy Breast lumpectomy Chest reconstruction Other: Other than for surgery or childbirth, have you ever been in the hospital overnight? Has anyone in your family had any of the following? Diabetes Thyroid problems Blood clots/diseases High cholesterol Osteoporosis Breast cancer High blood pressure Parkinson s disease Colon cancer Heart attack Alzheimer s disease Ovarian cancer Heart surgery Mental illness Prostate cancer Stroke Alcohol/drug addiction Other: Are you allergic to any: medications foods animals/insects
2 What medicines (prescription and over-the-counter), vitamins, supplements and/or herbs do you take regularly? Name Dose When do you take it? What is it for? Do you often have trouble remembering to take medicines? Have you ever gotten a period? unsure Yes No How old were you when you first got your period? What was the date that your last normal period began? What are your periods like? I get one every days. It lasts for days. On my heaviest day, I use maxi pads/tampons. I get cramps with my period: If yes, how severe are they on a scale of 1 (low) to 10 (high)? _ Have you gone through menopause? unsure Yes No At what age? Have you had any bleeding since then? Have you ever taken hormone replacement? Do you currently take hormone replacement? If yes, what do you take? Estrogen/progesterone Estrogen alone Testosterone Other: Are you having any symptoms of menopause? If yes, which ones? Hot flashes Mood changes Vaginal dryness Insomnia other: When was your last vaccine for: HPV (Gardasil) Tetanus / TdaP Hepatitis A Hepatitis B Pneumonia (pneumovax) Chicken pox (varavax) Shingles (zostavax) date Did you receive childhood vaccinations? No I m not sure Yes
3 When was the last time you had a test for tuberculosis (TB)? Have you ever had a positive test for TB? If yes, did you complete 6 months of preventative treatment? If yes, which of the following symptoms do you have now? cough > 3 weeks unexplained weight loss coughing up blood drenching night sweats If no, have you had contact with someone known to have TB disease of the lung? Were you born in Asia, Africa, Latin America, or Eastern Europe? Have you spent more than 2 weeks in Asia, Africa, Latin America, or Eastern Europe in the past 2 years? Have you been in prison/jail in the past 5 years? Do you work with people who use drugs, are migrant workers, or are experiencing homelessness? Are you a health care worker? When was your last: Date Result HIV test unsure never Sexually transmitted infection test unsure never Hepatitis C test unsure never Bone density test unsure never Cholesterol test unsure never When was your last: Date Result Cervical Pap smear unsure never Anal Pap smear unsure never Mammogram unsure never Colorectal cancer unsure never Which test(s) you ve had: FOBT FIT Colonoscopy Other When was the last time you saw a dentist? How often in the past year have you had an alcoholic beverage? Daily or almost daily Less than monthly Weekly Never Monthly How often in the past year have you used an illegal drug or used a prescription medication for non-medical reasons? Daily or almost daily Less than monthly Weekly Never Monthly
4 Have you ever had sex with another person? In your lifetime your sexual partner(s) have been: (check all that apply) women transgender FTM genderqueer men transgender MTF other: Currently your sexual partner(s) are: (check all that apply) none women transgender FTM genderqueer men transgender MTF other: When was the last time you had sex with another person? In the past year, how many different sexual partner(s) have you had? Currently, how many sexual partner(s) do you have? Do you only have sex with each other? Are you practicing safer sex? Never Sometimes Always Do you think you or your sexual partner(s) may have a sexually transmitted infection right now? Are you having any difficulties with your sex life? Do you want to discuss this today? What sexually transmitted infection(s) have you had in the past? Gonorrhea Oral herpes Chlamydia Genital herpes Pelvic inflammatory disease Herpes through a blood test Syphilis Genital warts Trichomonas Other: Have you ever been pregnant? If yes, how many times have you been pregnant? How many abortions? How many premature births? How many miscarriages? How many full-term births? How many live children do you have now? Are you planning on getting pregnant? If yes, when? Do you or your partner(s) use any kind of birth control? If yes, what kind? Are you satisfied with this method? Could you or your partner(s) be pregnant today? What would you do if you or your partner(s) got pregnant? Not needed N/A Have you ever been non-consensually hit, slapped, kicked, or otherwise physically hurt by an intimate partner? If yes, when did this happen? Do you want to discuss this today? Have you ever been forced to have sexual activities against your will? If yes, when did this happen? Do you want to discuss this today?
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Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
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