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