OFFICE USE ONLY RHIO YES NO SURESCRIPTS YES NO Today`s

OFFICE USE ONLY RHIO YES NO SURESCRIPTS YES NO Today`s

OFFICE USE ONLY
RHIO
YES
NO
SURESCRIPTS
YES
NO
Today’s Date: ____________________________
Name___________________________________________________________________ Age_____________ DOB___________
Phone Number (Home) ___________________ (Work) ________________________ (Cell) _____________________________
E-Mail Address ____________________________________________________________________________________________
Primary Care Doctor ________________________________________________________________________________________
Preferred Pharmacy ____________________________________ Location ____________________________________________
What is the reason for your visit? ______ (Annual exam)
(Other) ___________________________________________
Current medication and dosage _______________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Medication Allergies __________________________________
Date of last: PAP Smear________
Colonoscopy_______
Pregnancy History:
Do you have a LATEX Allergy? ____ (yes) ____ (no)
Tetanus Shot __________
Mammogram________
Cholesterol Check________
HPV Vaccine (Gardasil) _________
# of pregnancies ______
# of deliveries ________
# of miscarriages _____
# of terminations ______
Bone Density_________
# of living children ______
# of ectopic _____
Please tell us about YOUR gynecological history.
When was the first day of your last menstrual period? _______________ Number of days between cycles? _________
Age of first period ________ Are cycles regular? ___ (yes) ___ (no)
Herpes
Endometriosis
Infertility
Colposcopy
Gonorrhea
Pelvic Pain
Ovarian Cancer
LEEP
Chlamydia
Ovarian Cysts
Uterine Cancer
Cryo (freezing)
Please check if YOU are being treated or have been treated for any of the following:
Anxiety
Colon Cancer
Heart Disease
Arthritis
COPD
High Blood Pressure
Asthma
Depression
High Cholesterol
Blood Clots
Diabetes
Irritable Bowel
Breast Cancer
Diverticulitis
Migraines
Other_____________________________________________________
Please check if YOU have had any of these surgeries/treatments, including dates.
Appendectomy
Heart Surgery
C-Section
Gallbladder
Back/Neck
D&C
Bowel
Breast
Tonsillectomy
Uterine Ablation
Genital Warts
Polycystic Ovaries
Heavy Periods
Other ______________
Osteoporosis/Osteopenia
Reflux/GERD
Seizures
Stroke
Thyroid Disease
Hysterectomy
Tubal Ligation
Ovarian
Name: ___________________________________________________
Please check if ANYONE in your immediate family (parents, siblings) ever had the following.
Breast Cancer
Stroke
Thyroid Disease
Colon Cancer
Heart Disease
High Cholesterol
Ovarian Cancer
Diabetes
Osteoporosis/Osteopenia
Uterine Cancer
Blood Clots
High Blood Pressure
Other _______________
Please CIRCLE if you are having a CURRENT problem with any of the following that you would like to discuss today.
Sudden Weight
Gain
Sudden Weight
Loss
Fatigue
Fever
Bleeding Gums
Mouth Sores
Sore Throat
Chest Pain
Shortness Of
Breath
Wheezing
Nausea
Vomiting
Rectal Bleeding
Hemorrhoids
Pain With
Intercourse
Irregular
Periods
Incontinence
Frequent
Urination
Urgent
Voiding
Dizziness
Numbness
Seizures
Poor Sleep
Impaired
Memory
Mood
Changes
Dry Skin
Easy Bleeding
Easy Bruising
Blood In
Urine
Trouble
Walking
Excessive
Sweating
Swollen
Lymph
Nodes
Changes In
Moles
Abnormal
Lumps
Spots
Before Eyes
Irregular
Heartbeat
Ear Ache
Ringing In
Ears
Swelling Of
Legs
Cough
Diarrhea
Constipation
Bloating
Vaginal
Dryness
Pelvic Pain
Pain With
Urination
Pain In
Joints
Muscle
Weakness
Skin
Changes
Fainting
Headache
Depression
Anxiety
Excessive
Thirst
Increased
Urination
Hot Flashes
Night
Sweats
Seasonal
Allergies
Food
Allergies
Medication
Allergies
Rash
Blurry Vision
Palpitations
Abdominal
Pain
Abnormal
Vaginal
Discharge
Swelling In
Joints
Your Occupation: ___________________________________________________________________________________
Marital Status: __________________________
Are you sexually active? ___ (yes) ____ (no)
with whom do you live ________________________________
Gender of partner(s): ___________________
Contraception use (methods):____________________________________________________
Do you preform self-breast exams? ____ (yes) _____ (no)
Do You?
Smoke
Drink Alcohol
Use Marijuana
Use Street Drugs
Exercise
No
No
No
No
No
Yes _____packs/day?
Yes, Occasionally
Yes, How Often:_____________________
Yes, List Drugs:______________________
Yes, How Often:_____________________
Do you take Calcium/Vitamin D?
Do you take a Multivitamin?
Do you use seat belts?
Do you have a Health Care Proxy
Are you being physically, sexually, or emotionally abused?
Do you want an HIV test?
Do you want any other STD testing?
Yes
Yes
Yes
Yes
Quit
Yes, Daily
No
No
No
No
Yes
Yes
Yes
No
No
No