Please print and complete this form prior to your arrival for your appointment to facilitate registration. 

 

Date ­­­­­­­­­­­­­­­­­­­­­________________
Home-
Work-
Mobile-
Email:

 

Name_________________________         Age________

Occupation_____________________________________

Name of Significant Other_________________________

Primary Care Physician____________________________

 Reason for today’s visit:  

 

Please List any Medical Conditions.  

 

Screening Test History:

Last Pap                         (year)___________  never had

                           -history of Abnormal Pap Smear?    No   Yes (type)___________

Last Colonoscopy          (year)___________Normal?    yes    no   never had

Last Bone Density         (year)___________Normal?    yes    no    never had

Last Mammogram         (year)___________Normal?    yes     no   never had

Last Pelvic Sonogram    ________________

 

Marital History: 

   Married__  Single__  Partnered__   Divorced__   Separated__  Widowed__

 

Obstetrical History:

How many pregnancies have you had?   ­_____

Number of live births:   Full term___  Premature____ C section___  Vaginal___

Number of miscarriages__      Number of elective terminations__

Number of currently living children___    adopted children___

 

Gynecologic History:

Last Menstrual Period     (first day)………………………………………___/__/____

Sexually active?……………………………………….Yes (__recent  __>1yr ago)  Never

Sexually active with?…………………………           Male___    Female ___    Both___

Number of sex partners in last year:……………………____

History of: HPV__ PID__ gonorrhea__ chlamydia__ herpes__ trichomonas__Yes       No

Do you want to be screened for Sexually Transmitted Diseases Today?……...Yes        No

Any history of irregular periods?………………………………………………Yes        No

Are your periods painful?……………………………………………………...Yes        No

Do you have pain with sex? …………………………………….………….….Yes        No

Do you have PMS?…………………………………………………………….Yes        No

Do you get hot flashes?…………………………………………………….. …Yes        No

Do you get vaginal dryness?……………………………………………….…..Yes       No

How old were you when you had your first period?……………………….…____ yrs old


 

Do you use contraception?………………………………………………………Yes     No

If yes: Condoms__   oral contraceptive pill__  IUD___  Depot Provera__  Nuvaring__ 

           Diaphragm__ Tubes tied__Vasectomy (partner)__ 

 

Any Urinary symptoms?…………………………………………………….….Yes      No

If yes: burning__   frequency__   blood in urine__

            losing urine when coughing, laughing or sneezing__  urgency to urinate___

waking up at night to urinate___

 

Do you smoke cigarettes? ……………If yes, how much?……………………..Yes     No

Do you use alcohol?                    __never    __occasionally     __routinely

Do you use recreational drugs?   __never    __occasionally     __routinely

Do you exercise?                         __rarely     __sometimes       __routinely

 

 

Family History:

Breast Cancer…………………………..……Yes …..No……Who?……………………..

Ovarian Cancer……………………………...Yes …..No……Who?……………………..

Colon Cancer…………………….…...……..Yes …..No……Who?……………………..

Other type of Cancer…………….…..…..…..Yes …. No……Who?……………………..

Diabetes………………………………...…...Yes…... No..…..Who?……………...………

High Blood Pressure………………….…..…Yes …..No……Who?………………………

Osteoporosis………………………………....Yes……No……Who?..................................

 

Surgical History                                                          Date of Surgery 

  

 Medications and Dosages                                                     

(taken on a daily basis including over the counter and complementary therapies)

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Allergies______________________________________Reaction_______________________________________________________________________________________________________________________________________________________

 

Do you have any questions for the doctor? ________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Do you have any interest in the following LASER and facial services?

 

Hair Removal__  Vein Therapy __  Skin Tightening __   Photo Genesis___

 

Microdermabrasion___  Chemical Peels___

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