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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:

May we leave detailed information about the results of medical testing or other personal medical information:
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Medical History

Medical History

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Marital Status:
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How did you hear about us:
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Do you have any bleeding or spotting between your periods?
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How many pads/tampons do you use per 24 hours on heavy days?

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Do you use a pad and tampon together?
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Do you soak through?
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Do you have menstrual cramps
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Menstrual Cramps level of pain:
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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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Please check if you have ever had:

What do you use for birth control

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Was it normal?
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Have you had any abnormal Pap smears?
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Was it normal?
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What is your sexual preference
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Have you ever been abused sexually, physically or emotionally?
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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
Do you currently smoke?
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Alcohol Use
Do you use alcohol?
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Recreational Drug Use
Do you use any recreational drugs?
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Caffeine Intake
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Vitamins and Supplements
Do you take vitamins or other supplements?
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In the last year, have you considered suicide?
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What is your ethnic heritage? (This may be relevant to your medical care)
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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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Have you received a blood transfusion?
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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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