Patient Questionnaire - updated June 2021

Patient Questionnaire
Date*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Social Security Number*
Current marital status*

SingleMarriedWidowedDivorcedSeparated
Current Occupation
Do you smoke?*

YesNo
If so, how much?
Do you drink alcohol?*

YesNo
If so, how much?
What do you do for exercise?*
Who is your primary care doctor?
When was the last time you had the following tests?
Cholesterol

MonthDayYear
Date
Bone density

MonthDayYear
Date
Pap

MonthDayYear
Date
Mammogram

MonthDayYear
Date
Colonoscopy

MonthDayYear
Date
Are you having periods?*

YesNo
Are you menopausal (stopped having periods)?

YesNo
If so, when did the last one start?

MonthDayYear
Date
At what age did you stop having a period?
List drug allergies*
List current medications*
Please list preferred pharmacy and location*
Have there been changes with your family medical history?*

YesNo
If so, what changes?
Have there been changes with your personal medical history or have you had any surgeries?*

YesNo
If so, what changes?
Medicare will pay for a pap smear every other year. It is recommended of this ofce that you have yearly pap smears; however, we understand that financially it may not be feasible. The cost is $78 if Medicare does not pay for it, and if Medicare does not pay, your secondary will not pay.
Please choose one of the following

I DO NOT want my pap smear done this year if it was done last year.I DO want my pap smear done this year.
(Please note that we will file all charges to Medicare and secondary insurances before billing you. )
Are you interested in: (Check All That Apply_

Permanent Hair RemovalStretch Mark ReductionScar ReductionSkin RejuvenationBody ContouringVaginal RejuvenationReduction of Wrinkles, Sun Damage and Facial Veins
For Medicare Patients Only

Medicare will pay for a pap smear every other year. It is recommended of this office that you have yearly pap smears; however, we understand that financially it may not be feasible. The cost is $78 if Medicare does not pay for it, and if Medicare does not pay, your secondary will not pay. Please choose ONE of the following:
Please choose one

I DO NOT want my pap smear done this year if it was done last year.I DO want my pap smear done this year.
Sign Here

Clear
(Please note that we will file all charges to Medicare and secondary insurances before billing you).
Should be Empty: