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ADVANCED WOMENS HEALTH INSTITUTE

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In Case of Emergency, Please notify:
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I acknowledge that I have received and understand my rights under HIPPA regulations. I authorize the release of information to my insurance as needed to process my claim I have read the financial, after hours and cancellation policy and understand and accept.
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Please indicate below to whom we may speak with regarding the medical care we provide to you within this office or the hospital:
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Please let us know the best way to contact you about results of any medical tests:
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Medical History


Medical History

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How many pads/tampons do you use per 24 hours on heavy days?
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Obstetrical History
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Birth #1
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Birth #2
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Birth #3
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What do you use for birth control
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Surgical History
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Medical History


Medical History

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Social History


Social History

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Exercise
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Tobacco Use
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Alcohol Use
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Recreational Drug Use
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Caffeine Intake
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Vitamins and Supplements
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Family History


Family History

Have you had any relatives with cancer of the breast, colon, female organs, lung, prostate, skin or other cancer. If so please list below:
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Family Tree


Family Tree

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Patient Medication / Diagnosis and Treatment Summary
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Prescription #1
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Prescription #2
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Prescription #3
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Herbs and Vitamins
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Herbs and Vitamins #2
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