ADVANCED WOMENS HEALTH INSTITUTE

Patient First Name

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Middle Initial:

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Patient Last Name

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Date of Birth:

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Email Address

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Street Address:

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City:

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State:

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Zip:

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Home Phone:

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Cell Phone:

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Spouse’s Name:

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In Case of Emergency, Please notify:

Name:

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Relationship:

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Phone:

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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.

Signature:

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Date:

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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:

Myself only

Spouse/Significant

Other:

If Other, Please list Name:

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Please let us know the best way to contact you about results of any medical tests:

Cell Phone

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

Yes

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Printed Patients Name:

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Signature:

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Date:

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Medical History

Age:

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Marital Status:

Single

Married

with Significant Other

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Partners Name:

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Age:

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Referred by:

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What problems would you like to discuss today?

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What was the first day of your last menstrual flow?

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How old were you when you started your period?

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How many days between the first day of one period and the first day of the next period?

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Do you have any bleeding or spotting between your periods?

Yes

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How many days does the flow last?

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How many are heavy?

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How many pads/tampons do you use per 24 hours on heavy days?

Pads?

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Tampons?

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Do you use a pad and tampon together?

Yes

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Do you soak through?

Yes

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If yes, how often?

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Do you have menstrual cramps

Yes

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If yes how many days?

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Menstrual Cramps level of pain:

Mild

Moderate

Severe

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What over the counter or prescription medications do you use to relieve menstrual cramps:

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Dose:

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How often?

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Obstetrical History

Number of pregnancies:

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Live Births:

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Miscarriages:

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Elective abortions:

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Living Children:

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Birth #1

Date of Birth

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Vaginal

Cesarean

Complications:

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Birth #2

Date of birth:

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Vaginal

Cesarean

Complications:

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Birth #3

Date of birth:

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Vaginal

Cesarean

Complications:

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Additional Births (Please provide DOB, Type of Delivery, and Complications)

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Please check if you have ever had:

Uterus removed

Cervix biopsy

Cervix frozen

Pelvic (tubal) infection

Ovarian cysts

Endometriosis

Ovaries removed

Syphilis

Chlamydia

Genital warts

Gonorrhea

Genital herpes

Pain with intercourse

Pelvic Pain

PMS

D&C

Yeast Infection

Hot Flashes

Infertility

What do you use for birth control

nothing

trying to conceive

the Pill

IUD

sponge

diaphragm

spermicide

Rhythm

condoms

partner with vasectomy

tubal ligation

other:

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Date of last mammogram:

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Date of last Pap Smear

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Was it normal?

yes

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Have you had any abnormal Pap smears?

yes

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Was it normal?

Yes

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What is the frequency of your sexual activity?

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How many sexual partners do you now have?

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How many different sexual partners have you had during your lifetime?

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What is your sexual preference

Heterosexual

Lesbian

Bisexual

Other

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Have you ever been abused sexually, physically or emotionally?

Yes

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Surgical History

Date:

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Type of Surgery:

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Date:

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Type of Surgery:

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Date:

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Type of Surgery:

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Date:

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Type of Surgery:

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Date:

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Type of Surgery:

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Medical History

Please check if you have ever had:

Eczema

Skin Cancer

Psoriasis

Cataracts

Contact Lens/Glasses

Glaucoma

Dentures

Hay Fever

Hearing Loss

Asthma

Heart Attack

Pacemaker

Rheumatic Fever

High Blood Pressure

High Cholesterol

Breast Cancer

Diabetes

Fibrocystic Breast

Blood Clots Legs

Blood Clots Lungs

Eating Disorder

Colon Polyps

Crohn’s Disease

Gallstones

Hemorrhoids

Hepatitis Liver Disease

Hiatal Hernia

Irritable Bowel

Pancreatitis

Stomach Cancer

Colon Cancer

Ulcers

Abnormal Kidney

Kidney Stones

Bladder Infections

Incontinence

Osteoporosis

Thyroid Problems

Migraines

Seizures

Stroke

TIA (Mini Stroke)

Degenerative Arthritis

Gout

Herniated Disk

Rheumatoid Arthritis

Chronic Back Pain

AIDS

Anemia

Bleeding Problem

Leukemia

Alcoholism

Depression

Drug Abuse

Social History

What is your occupation?

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Exercise

What do you do for exercise?

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How many days per week?

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For how many minutes?

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Tobacco Use

Do you currently smoke?

Yes

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How much do you currently smoke?

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How many years have you or did you smoke?

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When did you quit?

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Alcohol Use

Do you use alcohol?

Yes

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How much alcohol do you use?

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Drinks per day:

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Drinks per week:

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Drinks per month:

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Recreational Drug Use

Do you use any recreational drugs?

Yes

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If yes which ones:

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Caffeine Intake

How much caffeine do you drink per day?

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Coffee:

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Tea:

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Soda:

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Vitamins and Supplements

Do you take vitamins or other supplements?

Yes

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If so what kind and how much?

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In the last year, have you considered suicide?

Yes

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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:

Relationship to Patient:

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Type of Cancer:

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Relationship to Patient

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Type of Cancer

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Relationship to Patient:

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Type of Cancer:

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Family Tree

Mother:

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Grandmother (Maternal):

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Grandfather (Maternal):

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Father:

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Grandmother (Paternal):

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Grandfather (Paternal):

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Siblings

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Have you received a blood transfusion?

Yes

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Why?

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Allergies and adverse reactions If you have had an adverse reaction to medication, chemicals, foods, etc., list what caused the reaction and the type and severity of the reaction:

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Patient Medication / Diagnosis and Treatment Summary

Would you like a chaperone in the room?

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Prescription #1

Prescription Medication:

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Dose and Frequency:

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Prescription #2

Prescription Medication:

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Dose and Frequency:

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Prescription #3

Prescription Medications:

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Dose and Frequency:

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Additional Prescriptions (List Medication Name, Dose, and Frequency)

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Herbs and Vitamins

Herbs and Vitamins:

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Dose:

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Frequency:

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Herbs and Vitamins #2

Herbs and Vitamin Details (List Name, Dose, and Frequency for all Herbs and Vitamins)

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