Medical History
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How many pads/tampons do you use per 24 hours on heavy days?
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What over the counter or prescription medications do you use to relieve menstrual cramps:
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Please check if you have ever had:
What do you use for birth control?
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What is the frequency of your sexual activity?
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Surgical History
Surgical History
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Medical History
Medical History
Please check if you have ever had:
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Social History
Social History
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How much caffeine do you drink per day?
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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
Please list any health problems, like the ones in the medical history section that relatives may have had, such as diabetes, high blood pressure, etc.
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Allergies and adverse reactions
Allergies and adverse reactions
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Patient Medication / Diagnosis and Treatment Summary
Patient Medication / Diagnosis and Treatment Summary
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