Patient Name:
DOB:
Age:
Date of last annual exam:
1st day of last period:
Primary Care MD:
Referring MD:
Please check if anything listed applies to you
Urine
Frequency
Urgency
Burning
Incontinence
Pain
Vagina
Dryness
Itching
Discharge
Painful Intercourse
Bleeding after intercourse
Menstrual
Irregular periods
Cramps
Heavy periods
Menopause
Hot Flashes
Night Sweats
Bleeding
Insomia
Other
STD
AIDS/HIV
Chlamydia/Gonorrhea
Genital Warts
Herpes
Cancer History
Are you sexually active?
Yes
No
Do you have multiple sexual partners?
# Partners in Last Year
# Lifetime Partners
Is/Are your partner(s)
Male
Female
Both
Is anyone physically, sexually, or emotionally hurting you?
History of sexual abuse?
Current Contraception (including tubal ligation, vasectomy, condoms, etc)
Please check if you are now or recently have experienced any of the following
Constitutional
Fatigue
Sweating
Unusual Weight Gain
Unusual Weight Loss
Eyes
Double Vision
Spots
Vision Loss
Ear/Nose/Throat
Ringing in Ear
Earache
Sore Throat
Bleeding Gums
Congestion
Cardiac
Chest Pain
Palpitations
Swelling/Edema
Respiratory
Wheezing
Cough
Shortness of Breath
GI
Constipation
Diarrhea
Bloating
Black or Bloody Stools
Muscle
Joint Pain
Muscle Cramps
Weakness
Skin
Rash
Lesions
Acne
Moles
Breast
Lump
Fibrocystic
Skin Changes
Neuro
Headaches
Tremors
Seizures
Endocrine
Excess Thirst
Hair Loss
Hair growth
Cold/Heat Intolerance
Lymph
Bruising
Nosebleeds
Swollen Glands
Psych
Anxiety
Depression
Mood Swings
PMS/PMDD
Eating Disorder
Marital Status
Single
Married
Divorced
Widowed
Separated
Partnered
Are you employed?
Do you have carbon monoxide indicators in your home?
Do you have smoke detectors in your home?
Do you use street drugs?
Marijuana
Do you use alcohol?
Tobacco/e-cig products?
Exercise
None
Routine of
Do you wear seat belts?
Special diet:
Weight Loss
Low Fat
Vegan
Diabetic
Vegetarian
Low Carb
Do you drink caffeinated beverages?
Please list current medications you are taking along with the strength and dose.
What concerns do you want to discuss at today’s appointment?
Were you or any family member diagnosed with a new medical condition since your last visit?
Have you had surgeries or hospitalizations since last time here?
Do you have specific requests for:
New Medication(s):
Refills:
Vaccinations:
Referrals:
Tests:
Completion of forms:
School or work release:
Patient’s Signature:
Date:
