General Patient Information
Patient Name
*
First Name
Last Name
Patient Birth Date
*
January
February
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April
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June
July
August
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October
November
December
Month
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Day
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1929
1928
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1926
1925
1924
1923
1922
1921
1920
Year
Patient Height (Ft, Inches)
*
Patient Weight lbs)
*
Patient E-Mail
*
Reason for seeing the doctor:
*
Patient Medical History
Have you ever had (Please check all that apply)
*
Alcohol/drug addiction
Anemia
Arthritis
Arrhythmia
Asthma
Bleeding Disorders
Blood Clots
Blood Transfusion
Bowel Problems
Broken Bones
Cancer
Cataracts
Chickenpox
Collagen Vascular Disease
Depression/Anxiety
Gout
Diabetes
Eating Disorder
Emotional Disorder
Epilepsy Seizures
Fainting Spells
Gallbladder Disease
Gallstones
Glaucoma
Headaches
Heart Disease/attacks
Heart Murmur
Hepatitis
High Blood Pressure
High Cholesterol
HIV/Aids
Joint/Back Pain
Kidney Infections
Kidney Stones
Lung Disease
Osteoporosis
Pneumonia
Reflux/Ulcers
Rheumatic Fever
Seizures/Epilepsy
Sickle Cell
Stroke
Thyroid Disease
Tuberculosis
None
Other illnesses:
Past Surgical/Injury History
(Date: And Type of injury/surgery)
Past Surgical/Injury History Continued
*
(Date: And Type of injury/surgery)
Past Surgical/Injury History Continued
(Date: And Type of injury/surgery)
Please list any Allergies/Drug/Food/Other Trigger
(Please list type of reaction also)
Allergies/Drug/Food/Other Trigger continued
(Please list type of reaction also)
Any Medications? Please list hormones, vitamins, herbs and non prescription medications
Medications continued~ Please list hormones, vitamins, herbs and non prescription medications
Sexual Orientation
*
Heterosexual
Homosexual
Bisexual
Other
Marital Status
Single
Married
Divorced
Widowed
Living with Partner
Number Of people living in your household?
Current Job
Do you travel outside the US?
Yes
No
Do you smoke?
No
0-1 pack/day
1-2 packs/day
2+ packs/day
Have you ever smoked?
Yes
No
Type a question
Type a question
Type a question
Number of years:
Number of packs a day:
Do you exercise regularly?
*
Never
1-2 days
3-4 days
5+ days
Alcohol Consumption
*
I don't drink
1-2 glasses/day
3-4 glasses/day
5+ glasses/day
Caffeine Consumption
*
I don't use caffeine
1-2 cups/day
3-4 cups/day
5+ cups/day
Have you ever used recreational drugs?
*
Yes
No
Please quantify your dairy intake or calcium supplement usage:
Have you ever been sexually abused, threatened or hurt by someone?
*
Yes
NO
Family History
Mother
Living
Deceased
Cause/Age
Father
Living
Deceased
Cause/Age
Number of Children
Number of living siblings:
Deceased Siblings?
Yes
No
Cause/Age
Family History of the Following -Select all that Apply
*
Alcohol/Drug addiction
Alzheimer's
Birth Defects
Blood Clots
Breast Cancer
Colon Cancer
Cystic Fybrosis
Diabetes
Heart Disease/Attack
Hepatitis
High Blood Pressure
High Cholesterol
HIV/Aids
Mental Illness/Depression
Osteoporosis
Ovarian Cancer
Stroke
Tuberculosis
Uterine Cancer
Thyroid Disease
None
Gynecological History
First Day of your last menstrual period:
 -
Month
 -
Day
Year
Date
Age at your first period
Usual number of days bleeding with menses:
How often do you have your periods? (i.e. 28 days)
Any menstrual abnormalities?
Age at Menopause (if applicable)
Have you ever had sex?
Yes
No
Are you currently sexually active?
Yes
No
Are your sexual partners:
Men
Women
Both
Other
Any history of sexually transmitted diseases?
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Present Method of Birth Control
Have you ever used birth control or hormone replacement therapy?
Yes
No
If Yes, which and for how long?
When was your last PAP test?
 -
Month
 -
Day
Year
Date
Have you ever had an abnormal PAP?
Yes
No
Do you perform regular breast self-exams?
Yes
No
Date of last mammogram:
 -
Month
 -
Day
Year
Date
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Obstetric History
Please include information about all of your pregnancies, births, miscarriages, abortions, ectopic (tubal)
Date of first pregnancy
 -
Month
 -
Day
Year
Date
Weight/sex/place delivered/type of delivery/complications?
Date of Second Pregnancy
 -
Month
 -
Day
Year
Date
Weight/sex/place delivered/type of delivery/complications?
Date of Third Pregnancy
 -
Month
 -
Day
Year
Date
Weight/sex/place delivered/type of delivery/complications?
Date of Fourth Pregnancy
 -
Month
 -
Day
Year
Date
Weight/sex/place delivered/type of delivery/complications?
Date of Fifth Pregnancy
 -
Month
 -
Day
Year
Date
Weight/sex/place delivered/type of delivery/complications?
Date of Sixth Pregnancy
 -
Month
 -
Day
Year
Date
Weight/sex/place delivered/type of delivery/complications?
Immunizations
Please fill in date in mm/dd/yyyy beside each immunization. If you're unsure add an approximate date.
Tetanus-Diphtheria Booster:
 -
Month
 -
Day
Year
Date
Pneumoccocal Vaccine
 -
Month
 -
Day
Year
Date
Varicella Vaccine
 -
Month
 -
Day
Year
Date
Flu Vaccine
 -
Month
 -
Day
Year
Date
Gardasil Vaccine
 -
Month
 -
Day
Year
Date
Hepatitis B Vaccine
 -
Month
 -
Day
Year
Date
Measles-Mumps-Rubella Vaccine
 -
Month
 -
Day
Year
Date
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Pharmacy Name
Pharmacy Phone Number
Pharmacy Address
Review of Systems
Please check any of the following that apply to you.
General
*
Change in appetite
Change in Height
Difficulty Sleeping
Fatigue
Fever
Night Sweats
Weight Gain
Decreased libido
Weight Loss
None
Ear, Nose, Throat
*
Congestion
Earaches
Neck Mass
Recurrent Ear infections
Seasonal allergies
Dental Problems
Hearing problems
Neck Stiffness/pain
Ringing in Ears
Sinus problems
Difficulty Swallowing
Mouth Sores
Nose Bleeds/bleeding gums
Runny nose
Sore Throat
None
Vision
*
Blurred vision
Double vision
Vision changes
Glasses/contacts
N/A
Cardiovascular
*
Chest pain or pressure
Palpitations
Difficulty breathing with exertion
Leg Pain
Rapid or irregular heart beat
Difficulty breathing when laying flat
Leg Swelling
Varicose veins
N/A
Respiratory
*
Chronic Cough
Shortness of breath
Difficulty breathing with exertion
Coughing up blood
Rapid or irregular heart beat
Difficulty breathing when lying flat
Painful breathing
None
Gastrointestinal
*
Abdominal mass
Bloody stools
Hemorrhoids
Juandice
Abdominal pain
Constipation
Incontinence of stool or gas
Nausea/vomiting
Black stools
Diarrhea
Indigestion
Rectal Pain
N/A
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Please select any that apply
*
Abdominal bleeding
DES exposure
Frequent urination
Incontinence of urine
Painful intercourse
Premenstrual syndrome
Vaginal dryness
Absence of periods
Fibroids
History of endometriosis
Infertility
Painful periods
Urgency to urinate
Vaginal itching
Blood in urine
Frequent bladder infections
Incomplete empyting
Pain with urination
Pelvic pain
Vaginal discharge
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Musculoskeletal
Check all that apply
*
Back pain
Muscle pain
Joint pain/stiffness
Muscle weakness
Joint swelling
N/A
Skin
Check any that apply
*
Acne
Discoloration
Dry skin
Easy bruising
Moles
Enlarged lymph nodes
Rash
Itching
sores
N/A
Breasts
Check any that apply
*
Breast mass
Nipple discharge/blood
Breast pain
Breast swelling
N/A
Neurologic
Check any that apply:
*
Difficulty waking
Memory problems
Tremor
Dizziness
Numbness
Headaches
Seizures
N/A
Psychiatric
Check any that apply:
*
Anxiety
Depression
Frequent Crying
N/A
Endocrine
Check any that apply:
*
Abnormal hair growth
Hair loss
Abnormal thirst
Heat/cold intolerance
Deepening of voice
Hot flashes
N/A
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