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Elizabeth Shadigian, MD Empowering WomanCare and Gynecology
Elizabeth Shadigian, MD Empowering WomanCare and Gynecology 2340 East Stadium Blvd, Ste 8 Ann Arbor, MI 48104 Tel 734-477-5100 Fax 734-477-5111 [email protected] Date & time of first appointment_________________________________ Please fill out as much of this form as you would like to. We will complete your health herstory together when we see you for your appointment. Please choose from any of the following to return this form: 1) bring it to your appointment 2)email the completed form to [email protected] 3) fax to 734-477-5111 Name _________________________________________________________ Last First Middle First name you prefer to use___________________________ Date of birth ______________________ Address _______________________________________________________________________________________ Street City State Zip Preferred phone __________________________ Alternate phone ________________________________________ Email ______________________________ Preferred pharmacy & phone #__________________________________ Would you like to be added to our e-mail list to receive periodic updates on classes, groups, events and new program offerings at WomanSafeHealth? (please check): Yes / No Would you like a reminder email for your next annual? Yes No If so, Month _______________ Year_________ Emergency contact person _________________________ Relationship _____________ Phone # _______________ Please bring insurance information with you, if you have any. Insurance policy holder name & date of birth _________________________________________ Name of person who referred you to WomanSafeHealth ______________________________________________ Your occupation _______________________________________ Reason for your visit today ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Health Herstory Last medical visit and with whom ________________________________________________________________ Primary health care provider _______________________ Address ___________________________________ Phone __________________________ Fax __________________________ (Info needed to send records) Other health care providers ____________________________________________________________________ Last pap test results and date __________________________________________________________________ Last cholesterol results and date _______________________________________________________________ Last mammogram results and date _____________________________________________________________ Do you do self breast exam? _______ ________________________________________________________________________________________ For Office Use Only Next Appointment __________________ Time Spent Together ____________ File ES to do Billing Dictation Dictation Started Receipt (circle client preference) Email Printed Both Neither Billing Started Billing Completed ___________________________________________________________________________________________________________ www.womansafehealth.com Copyright © 2016 by WomanSafeHealth, P.C. All rights reserved. Materials at this site may be reproduced for personal, non-commercial distribution only. Copies must include this copyright notice. Current medications and dosages _______________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Current herbs/supplements/homeopathic medications _______________________________________________ __________________________________________________________________________________________ Allergies and reactions _______________________________________________________________________ Major illnesses/diagnoses and dates __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Surgeries/hospitalizations and dates __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Gynecological Herstory First day of Last Menstrual Period, if applicable _______________ regular, every _____ days; or irregular ____ How old were you when your periods first started _____ length of flow ______ Recent changes in your period/any problems ______________________________________________________ Obstetrical Herstory Any herstory of infertility? ________ Total number of pregnancies _______ Number of biological, adopted, foster or step-children _______________ Number of months or years you have breastfed a baby ___________________ Family Herstory Please indicate if anyone in your immediate family has had any of the following and who it was (brother, sister, mother, father, maternal or paternal grandmother or grandfather): Alcoholism/addiction High blood pressure Breast/ovarian/endometrial cancer High cholesterol Colon/prostate cancer Osteoporosis Depression/bipolar disorder Stroke/clots in legs or arms (DVT) Diabetes Thyroid disease Heart disease/heart attack Other www.womansafehealth.com Copyright © 2016 by WomanSafeHealth, P.C. All rights reserved. Materials at this site may be reproduced for personal, non-commercial distribution only. Copies must include this copyright notice. Review of Systems Please check any of the following symptoms you have experienced in the last month: Constitutional Weight loss Anxiety Weight gain Difficulty sleeping Fever Headaches Fatigue Other Depression/sadness Glasses/contacts Drainage/congestion Headache Hearing loss Other Eyes/Ear/Nose/Throat Vision changes Sores Cardiovascular/Respiratory Difficulty breathing while lying on back Chest pain Swelling Wheezing Shortness of breath Gastrointestinal Diarrhea Flatulence (gas) Difficulty breathing on exertion Palpitations Other Coughing up blood Cough Bloody stool Nausea/vomiting/indigestion Fecal incontinence (losing stool) Constipation Pain Genitourinary Blood in urine Incomplete emptying Pain when urinating Urinary frequency Urinary urgency Can’t hold urine Vaginal dryness Pain with sex Hot flashes/flushes PMS Abnormal vaginal bleeding Abnormal or painful periods Unusual vaginal discharge Musculoskeletal Muscle weakness Muscle or joint pain Other Sores Pigmented lesions Discharge Masses Skin Rash Breast Breast pain Dry skin Other Other Neurologic Fainting spells Seizures Numbness Trouble walking Memory problems Other Endocrine Hair loss Hot flashes Heat/cold intolerance Very thirsty Other Other Swollen lymph nodes Illness(es) Bruises Unusual Bleeding Allergic reaction Other symptoms I'm concerned about... ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ www.womansafehealth.com Copyright © 2016 by WomanSafeHealth, P.C. All rights reserved. Materials at this site may be reproduced for personal, non-commercial distribution only. Copies must include this copyright notice.
