Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Email Address: May we leave a message? Home Work Cell PLEASE DO NOT LEAVE A MESSAGE Marital Status: Single Married Widowed Divorced Separated Occupation: FULL-TIME PART-TIME UNEMPLOYED RETIRED FULL-TIME STUDENT PART-TIME STUDENT EMPLOYER: EMPLOYER ADDRESS: CITY: STATE: ZIP CODE: DEPARTMENT: TELEPHONE NUMBER: ( ) Were you referred from another physician? yes no Name of referring physician Primary Physician: How did you hear about our practice? (please circle) FRIEND/FAMILY MEMBER : HOSPITAL NEWSPAPER TELEPHONE BOOK INTERNET(website) FACEBOOK OTHER: PREFERRED PHARMACY: EMERGENCY CONTACT INFORMATION IN CASE OF EMERGENCY, PLEASE NOTIFY: MAILING ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE #: RELATIONSHIP TO PATIENT: 1
I AUTHORIZE THE OFFICE OF ANDERSON OBSTETRICS AND GYNECOLOGY, PLLC TO RELEASE ANY INFORMATION REQUIRED IN THE COURSE OF MY EXAMINATION AND/OR TREATMENT TO THE FOLLOWING DESIGNATED PERSON. (THIS PERSON MAY BE SOMEONE OTHER THAN YOUR EMERGENCY CONTACT. IF NOONE, PLEASE INDICATE.) NAME: TELEPHONE NUMBER ( ) REASON FOR YOUR VISIT TODAY: GENERAL HEALTH Do you exercise regularly? yes no Self Breast examination monthly? yes no Do you follow a special diet? yes no If yes, please specify? Which response describes your general health? EXCELLENT GOOD FAIR POOR Are you able to perform normal activities at home? Yes No If no, explain: Are you currently or have you ever experienced mental, physical, emotional, or sexual abuse? Yes No If yes, please explain: Do you currently feel safe in your home? Yes No CIRCLE ANY SIGNIFICANT SYMPTOMS BELOW THAT YOU CURRENTLY HAVE CONSTITUTIONAL BREAST MUSCULOSKELETAL ENDOCRINE GENITOURINARY Fever breast pain joint pain excessive thirst heavy bleeding Chills breast lump joint swelling excessive urination bleeding between periods Night sweats breast discharge back pain heat/cold intolerance painful periods Hot flashes breast swelling weakness irregular periods Weight changes skin changes difficulty walking bleeding after intercourse Appetite changes numbness/tingling vaginal discharge/odor Vaginal dryness Vaginal itching CARDIOVASCULAR RESPIRATORY GASTROINTESTINAL NEUROLOGIC vaginal sores Chest pain shortness of breath nausea headaches abnormal growths Palpitations cough vomiting seizures pelvic pain sputum production constipation weakness pelvic fullness/pressure diarrhea change in sexual desire 2
Abdominal pain change in sex partner PSYCHOLOGICAL Bloating/cramping sexual difficulty Depression Change in appetite pelvic prolapse Anxiety Bloody stool pain with intercourse Mood swings Black, tarry stool pain with urination Nervousness MENSTRUAL HISTORY First day of your last menstrual period? / / Number of days bleeding Flow: Light Medium Heavy Number of days between periods? Pain with periods? Yes No Bleeding between periods? Yes No Bleeding after intercourse? Yes No At what age did your periods start? At what age did your periods stop: OB/GYN HISTORY Current contraceptive method(s): Are you sexually active? Yes No Partner: Male Female Have you ever had a sexually transmitted infection? Yes No If yes, please list: Have you ever had Pelvic Inflammatory Disease? Yes No If yes, when: Are you currently using Hormone Replacement Therapy? Yes No If yes, what type?: Do you have pain with intercourse? Yes No N/A Vaginal dryness or discomfort? Yes No Number of pregnancies Live births Miscarriages Ectopics Elective terminations Number of Living Children Age and sex of Living Children: Date of last delivery: Number of vaginal deliveries: Number of cesarean deliveries Any pregnancy complications? Date of last Pap smear: Where was last Pap smear done? Have you ever had an abnormal Pap smear: Yes No If yes, when? Was it treated with any of the following? Frequent follow-up Pap smears Colposcopy Biopsy Cryotherapy Cone biopsy LEEP Hysterectomy Date of last Mammogram: Where was your last Mammogram done? Date of last Bone Density scan: Where was Bone Density scan done? 3
Date of last Colonoscopy: Where was colonoscopy done? Have you ever had chronic pelvic pain? Yes No Do you have pain now? Yes No If yes, location: On a scale of 1-10, how do you rate your pain? No pain 1 2 3 4 5 6 7 8 9 10 Worst possible pain SOCIAL HISTORY Tobacco use yes no How much? packs/day Former Smoker yes no Alcohol use yes no How much? drinks /week Drug use yes no If yes, list the type Caffeine use yes no How much? cups/day MEDICATIONS MEDICATION DOSE WHAT ARE YOU TAKING IT FOR ALLERGIES MEDICATION REACTION 4
FAMILY HISTORY Is your Mother alive? yes no If no, age and cause of death: Is your Father alive? yes no If no, age and cause of death: How many brothers do you have? How many sisters do you have? LIST ALL RELATIVES WHO HAVE HAD A MAJOR ILLNESS (DIABETES, HEART DISEASE, CANCER, HIGH BLOOD PRESSURE ) RELATION TYPE OF ILLNESS AGE AT DIAGNOSIS MEDICAL HISTORY DATE MEDICAL PROBLEM PHYSICIAN SURGICAL HISTORY DATE SURGERY/PROCEDURE PHYSICIAN/HOSPITAL 5
If HYSTERECTOMY, what was removed? UTERUS ONE OVARY BOTH OVARIES Any prior procedures on your cervix? Any prior procedures on your breasts? Patient Name: Patient Signature: Physician Signature: Date: Date: 6