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Patient Questionnaire (Female)

Name:
Today’s Date:
Date of Birth:
Age:
Occupation:
Home Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work:
Email Address:
How did you hear about us?
Patient Name:
Event:
Practitioner Name:
Pharmacy Name:
Social Media Type:
TV Station:
Radio Station:
Web Keyword Searched:
Signage
Print Ad seen in:
In Case of Emergency Contact:
Relationship:
Cell Phone:
Home Phone:
Work:
Pharmacy Name:
Phone:
Address:
Primary Care Physician’s Name:
Phone:
Address:
OBGYN Physician’s Name:
Phone:
Address:
May we share your clinical information with your PCP/Gyn?
Yes
No
MEDICAL HISTORY
Weight:
Last Menstrual Period:
Hysterectomy?
No
Partial
Full
Have you ever had any issues with anesthesia?
Yes
No
Do you smoke?
Yes
No
Quit
How much?
How often?
Age started?
Do you drink alcohol?
Yes
No
Quit
How much?
How often?
Age started?
Any known drug allergies:
Yes
No
If yes please explain:
Current Medications and dosage:
Nutritional/Vitamin Supplements:
Current Hormone Replacement Therapy:
Past HRT:
Surgeries, list all and when:
Other Pertinent Information:
Do you have a family history of?
Heart Disease
Cancer
Diabetes
Other:
Preventative Medical Care:
Medical/GYN Exam in the last year.
Mammogram in the last 12 months.
Bone Density in the last 12 months.
Pelvic ultrasound in the last 12 months.
Birth Control Method:
Menopause.
Hysterectomy.
Tubal Ligation.
Birth Control Pills.
Vasectomy.
Other:
High Risk Past Medical/Surgical History:
Breast Cancer.
Uterine Cancer.
Ovarian Cancer.
Hysterectomy with removal of ovaries.
Hysterectomy only.
Oophorectomy Removal of Ovaries.
Medical Illnesses:
High blood pressure.
Heart bypass.
High cholesterol.
Hypertension.
Heart Disease.
Stroke and/or heart attack.
Blood clot and/or a pulmonary emboli.
Arrhythmia.
Any form of Hepatitis or HIV.
Lupus or other auto immune disease.
Fibromyalgia.
Trouble passing urine or take Flomax or Avodart.
Chronic liver disease (hepatitis, fatty liver, cirrhosis).
Diabetes.
Thyroid disease.
Arthritis.
Depression/anxiety.
Psychiatric Disorder.
Cancer Type:
Year:

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