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APPOINTMENTS

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APPOINTMENTS

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Yearly Well Woman Exam Form

Date

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First Name

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Last Name

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Email

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Date of Birth

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Age

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Allergies & reaction to allergen?

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None

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Last menstrual period

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Periods are

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Length

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Cramps

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Meds for cramps

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Current Contraception

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Bleeding between periods?

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Number of pregnancies

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Number of deliveries

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Vaginal

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C-Section

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Date of last Pap

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Was it normal?

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Any abnormal paps?

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Date of last mammogram

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Any abnormal Mammograms?

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Breast cancer in your family?

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If Yes, who?

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Date of Colon Cancer Screen

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Colon cancer in your family?

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If Yes, who?

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Date of Bone Density Scan

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Osteoporosis in your family?

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If Yes, who?

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Reason for today’s visit – any problems you would like to address with the Dr.

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Medications, Herbs and Vitamins Drug/Dose/Frequency

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Medical Issues

Diabetes

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Heart Attack

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Thyroid Disease

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Headaches

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Anemia

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DVT (Blood Clots)

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High Blood Pressure

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Kidney disease

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Other:

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Family History

Diabetes

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Heart Attack

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Thyroid Disease

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Headaches

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Who?

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Who?

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Who?

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Who?

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Anemia

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DVT (Blood Clots)

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High Blood Pressure

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Kidney disease

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Who?

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Who?

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Who?

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Who?

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Please list any surgeries:

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Please list any surgeries:

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Please list any surgeries:

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Please list any surgeries:

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Please list any surgeries:

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Please list any surgeries:

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Social History

Relationship Status:

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Sexually Active?

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Exercise routine?

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Do you smoke?

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Amount?

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How long?

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Former smoker: Year Quit

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How much Coffee?

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Tea?

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Cokes?

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Do you drink daily?

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How much alcohol do you drink (preference)?

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Do you use drugs recreationally?

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Type:

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Are you under a lot of pressure at work?

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Type of work:

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Medical History

General Health:

Weight Loss

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Weight Gain

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Fever

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Fatigue

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Other:

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Eyes:

Vision Change

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Glaucoma

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Cataracts

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Other:

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Mouth/Nose:

Ulcers

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Sinusitis

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Headaches

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Other:

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Heart:

Chest Pain

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Palpitations

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Difficulty breathing

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Other:

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Respiratory:

Wheezing

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Cough

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Sputum Production

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Other:

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GI:

Diarrhea

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Constipation

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Excess gas

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Other:

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Urinary:

Incontinent

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Urgency

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Frequency

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Other:

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Muscle/Skeletal:

Weakness

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Joint pain

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Other:

Easy bleeding

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Swollen Lymph Nodes

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Other:

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Allergy Immune:

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Would you like a chaperone in the room?

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