Female New Patient Questionnaire
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- Jennifer Dawson
- 5 years ago
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1 Patient Demographics First Name: Middle: Last Name: Home Phone: Cell Phone: Address: SSN: City: State: Zip: Age: Date of Birth: Referred by: OBGYN: Occupation: Primary Care Physician: Marital Status: Employer: Medical Information Last Menstrual Period: Number of Pregnancies: Height: Weight: Number of Children: Blood Pressure: (Office use only) Emergency Contact Information Name: Primary Phone: Relationship: Secondary Phone: Reason for Visit: Page 1 of 7
2 Allergies (List all allergies - Food, Drug, Other) Current Medications (List all current medications) Drug Dose How Often? Supplements (List all current supplements) Supplement Dose How Often? Page 2 of 7
3 Symptoms of Hormonal Deficiencies (check all that apply) Decreased or absent sex drive (libido) Fatigue and lack of energy Infrequent or absent orgasms Change in mood, anxiety and/or depression Insomnia Declining mental ability and memory Feeling of hopelessness and no motivation New migraine headaches Diminished strength and exercise tolerance Muscle shrinkage Joint aches and/or new onset of arthritic symptoms Dry eyes Poor balance and coordination Weight gain New or increased cellulite Ringing in the ears Hot flashes and night sweats Dry vagina or painful intercourse Dry and wrinkled skin Height has decreased, osteoporosis or osteopenia Bladder spasms Bladder infections PMS Felt better when I was pregnant Cold all the time Swelling all over the body Constipation Hair falling out or breaking off Brittle nails Stay up for over 24 hours Difficulty taking oral birth control pills Birth Control Method (Check all that apply). You must be in menopause, have had a hysterectomy, or use birth control to use pellet therapy Menopause Hysterectomy Tubal ligation Birth control pills Abstinence Vasectomy Mirena IUD Other IUD Page 3 of 7
4 Past Surgeries (List year of surgery) Habits (Check all that apply) Year Surgery Lap Band Surgery or Obesity Surgery Hysterectomy Open Heart Surgery Joint Replacement Cancer Surgery Pacemaker Removal of ovaries Smoking Cigarettes Or Cigars I Drink More Than 10 Drinks of Alcohol/Week I am a Recovering Alcoholic I Use or Have Used Marijuana In Past Year I Use or Have Used Cocaine I Use or Have Used Heroin Medical History (Check all that apply) Hepatitis or HIV (List Type) Breast cancer Uterine cancer Colon cancer Ovarian cancer Other cancer Blood clot or clotting disorder Heart attack Stroke Vascular disease High blood pressure High cholesterol Heart arrhythmia Emphysema (COPD TB (Tuberculosis) Glaucoma ADD, ADHD Depression/Anxiety Manic depression (bipolar) or mania Schizophrenia Leber s Optic Neuritis Psychological/psychiatric illness Restless leg Sleep apnea Narcolepsy Arthritis Rheumatoid arthritis Osteopenia or osteoporosis Fibro myalgia Lupus or autoimmune disease Chronic disease Chronic fatigue Adrenal fatigue Multiple sclerosis Diabetes type I Diabetes type II Hypoglycemia Insulin Resistance Thyroid disease Hypo Hyper Addisons disease or Cushings disease Kidney disease Other Page 4 of 7
5 Exercise History (Check all that apply) I don t exercise I have a very physical job so I don t exercise in addition I exercise every day for _ minutes I exercise more than three times a week for over 50 minutes Normal daily activity is what I consider exercise I am a long distance runner I lift weights times a week Diet (Check all that apply) I eat anything I want I don t eat much but gain weight anyway I have gained weight in my belly since I turned 40 I eat a balanced diet, 3 times a day I eat 6 small meals a day I don t eat wheat (gluten intolerance) I limit carbohydrates I eat a low fat diet Atkins/South Beach Diet Vegan/Vegetarian Special diet or restrictions Page 5 of 7
6 Preventative Medical Care (Check all that apply) Medical/GYN exam in the last year Mammogram in last 12 months Bone density in last 12 months (if over 50) Pelvic ultrasound in last 12 months (If you have a uterus) Hormone Replacement I have used (Check all that apply) Oral pills synthetic (Ogen, Premarin, Estrace, etc.) Patch Vaginal ring Other Bioidentical Hormone replacement I have used (Check all that apply) Pills Pellets Creams/gels applied on the skin or in the vagina Sublingual or buccal tablets (dissolve in the mouth) Family History (Check all that apply) Heart Disease Breast Cancer Uterine cancer Stroke Arrhythmia Diabetes Alzheimer s / Dementia any type Blood clots Rheumatoid arthritis/lupus Thyroid disease high or low Osteoporosis Hemochromatosis I attest that all the information I give is true. Print Name: Signature: Date: Page 6 of 7
7 Communication Consent to Communicate Please indicate the ways you consent for to communicate with you Cell Phone Home Phone Work Phone Text Message Can contact (Yes/No) Can leave message (Yes/No) Do we have permission to speak with spouse/partner? Yes No Do we have permission to leave a message with spouse/partner? Yes No If yes, please list name(s) and relationship Print Name: Signature: Date: Page 7 of 7
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