Medical History
After you enter the name of the provider you are scheduled to see, the health form will be displayed.
Please select the name of the doctor you are scheduled to see.
Lynn D. Canavan, M.D.
Meghan Hansen, MD
Jacqueline Bullock, PA-C
My provider is not in the list
---------- Date of Birth ----------
First Name
Last Name
Month
Day
Year
Gender
January
February
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July
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November
December
1
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1911
1910
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1908
1907
1906
1905
1904
1903
1902
1901
1900
Male
Female
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In order to notify the clinic, please enter your name and other demographic information above and enter the name
of your provider below. The clinic will be notified that the provider's name is missing.
Provider Name
Patient E-Mail Address:
REVIEW OF SYSTEMS
Mark all symptoms you are
CURRENTLY
experiencing. If none apply in a category, mark
NONE
.
GENERAL
chills
night sweats
fatigue
weight gain (>10 lbs.)
fever
weight loss (>10 lbs.)
NONE
SKIN
rash
bruising
color changes
NONE
HEENT
headache
blurred vision
NONE
NECK
mass or lump
swollen glands
NONE
RESPIRATORY
chronic cough
difficulty breathing
NONE
BREAST
nipple discharge
breast mass
nipple pain
breast pain
change in breast size
breast swelling
skin changes
NONE
CARDIOVASCULAR
rapid heart rate
chest pain
shortness of breath
irregular heartbeat
swelling of extremities
NONE
GASTROINTESTINAL
abdominal pain
constipation
black tarry stools
diarrhea
bloody stools
nausea
change in bowel habits
vomiting
NONE
FEMALE GENITOURINARY
abnormal vaginal bleeding
pelvic pain
urinary complaints
vaginal discharge
menstrual irregularities
NONE
MALE GENITOURINARY
penile discharge
lump in testicle
prostate conditions
NONE
MUSCULOSKELETAL
muscle pain
bone pain
NONE
NEUROLOGIC
numbness
headaches
weakness
NONE
PSYCHIATRIC
insomnia
anxiety
panic attacks
depression
suicidal ideation
NONE
ENDOCRINE
heat intolerance
cold intolerance
hot flashes
hair changes
libido changes
NONE
HEMATOLOGY
anemia
enlarged lymph nodes
abnormal bleeding
nose bleeds
easy bruising
prolonged bleeding
NONE
PHYSICIANS
Referring Physician:
Primary Care Physician:
Gynecologist:
Other Physician(s) you wish us to update:
FAMILY HISTORY
Please indicate if any of your family members have a history of the following.
Items are listed multiple times to allow for multiple family members.
Family Member
Age when diagnosed
Breast Cancer
Mother
Father
Daughter
Son
Sister
Brother
Grandfather (Mother's Side)
Grandmother (Mother's Side)
Grandfather (Father's Side)
Grandmother (Father's Side)
Great Grandfather (Mother's Side)
Great Grandmother (Mother's Side)
Great Grandfather (Father's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Uncle (Mother's Side)
Aunt (Father's Side)
Uncle (Father's Side)
Great Aunt (Mother's Side)
Great Uncle (Mother's Side)
Great Aunt (Father's Side)
Great Uncle (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
Nephew (Mother's Side)
Nephew (Father's Side)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Family Member
Age when diagnosed
Breast Cancer
Mother
Father
Daughter
Son
Sister
Brother
Grandfather (Mother's Side)
Grandmother (Mother's Side)
Grandfather (Father's Side)
Grandmother (Father's Side)
Great Grandfather (Mother's Side)
Great Grandmother (Mother's Side)
Great Grandfather (Father's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Uncle (Mother's Side)
Aunt (Father's Side)
Uncle (Father's Side)
Great Aunt (Mother's Side)
Great Uncle (Mother's Side)
Great Aunt (Father's Side)
Great Uncle (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
Nephew (Mother's Side)
Nephew (Father's Side)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Family Member
Age when diagnosed
Breast Cancer
Mother
Father
Daughter
Son
Sister
Brother
Grandfather (Mother's Side)
Grandmother (Mother's Side)
Grandfather (Father's Side)
Grandmother (Father's Side)
Great Grandfather (Mother's Side)
Great Grandmother (Mother's Side)
Great Grandfather (Father's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Uncle (Mother's Side)
Aunt (Father's Side)
Uncle (Father's Side)
Great Aunt (Mother's Side)
Great Uncle (Mother's Side)
Great Aunt (Father's Side)
Great Uncle (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
Nephew (Mother's Side)
Nephew (Father's Side)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Family Member
Age when diagnosed
Ovarian Cancer
Mother
Daughter
Sister
Grandmother (Mother's Side)
Grandmother (Father's Side)
Great Grandmother (Mother's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Aunt (Father's Side)
Great Aunt (Mother's Side)
Great Aunt (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Family Member
Age when diagnosed
Ovarian Cancer
Mother
Daughter
Sister
Grandmother (Mother's Side)
Grandmother (Father's Side)
Great Grandmother (Mother's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Aunt (Father's Side)
Great Aunt (Mother's Side)
Great Aunt (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Family Member
Age when diagnosed
Ovarian Cancer
Mother
Daughter
Sister
Grandmother (Mother's Side)
Grandmother (Father's Side)
Great Grandmother (Mother's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Aunt (Father's Side)
Great Aunt (Mother's Side)
Great Aunt (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Type of Cancer
Family Member
Other Cancer
Brain
Breast
Cervix
Colon
Esophagus
Liver
Lung
Lymphoma
Melanoma
Nonmelanoma Skin
Ovary
Pancreas
Prostate
Rectal
Skin
Stomach
Thyroid
Uterus
Other
Mother
Father
Daughter
Son
Sister
Brother
Grandfather (Mother's Side)
Grandmother (Mother's Side)
Grandfather (Father's Side)
Grandmother (Father's Side)
Great Grandfather (Mother's Side)
Great Grandmother (Mother's Side)
Great Grandfather (Father's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Uncle (Mother's Side)
Aunt (Father's Side)
Uncle (Father's Side)
Great Aunt (Mother's Side)
Great Uncle (Mother's Side)
Great Aunt (Father's Side)
Great Uncle (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
Nephew (Mother's Side)
Nephew (Father's Side)
Type of Cancer
Family Member
Other Cancer
Brain
Breast
Cervix
Colon
Esophagus
Liver
Lung
Lymphoma
Melanoma
Nonmelanoma Skin
Ovary
Pancreas
Prostate
Rectal
Skin
Stomach
Thyroid
Uterus
Other
Mother
Father
Daughter
Son
Sister
Brother
Grandfather (Mother's Side)
Grandmother (Mother's Side)
Grandfather (Father's Side)
Grandmother (Father's Side)
Great Grandfather (Mother's Side)
Great Grandmother (Mother's Side)
Great Grandfather (Father's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Uncle (Mother's Side)
Aunt (Father's Side)
Uncle (Father's Side)
Great Aunt (Mother's Side)
Great Uncle (Mother's Side)
Great Aunt (Father's Side)
Great Uncle (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
Nephew (Mother's Side)
Nephew (Father's Side)
Type of Cancer
Family Member
Other Cancer
Brain
Breast
Cervix
Colon
Esophagus
Liver
Lung
Lymphoma
Melanoma
Nonmelanoma Skin
Ovary
Pancreas
Prostate
Rectal
Skin
Stomach
Thyroid
Uterus
Other
Mother
Father
Daughter
Son
Sister
Brother
Grandfather (Mother's Side)
Grandmother (Mother's Side)
Grandfather (Father's Side)
Grandmother (Father's Side)
Great Grandfather (Mother's Side)
Great Grandmother (Mother's Side)
Great Grandfather (Father's Side)
Great Grandmother (Father's Side)
Aunt (Mother's Side)
Uncle (Mother's Side)
Aunt (Father's Side)
Uncle (Father's Side)
Great Aunt (Mother's Side)
Great Uncle (Mother's Side)
Great Aunt (Father's Side)
Great Uncle (Father's Side)
Cousin (Mother's Side)
Cousin (Father's Side)
Niece (Mother's Side)
Niece (Father's Side)
Nephew (Mother's Side)
Nephew (Father's Side)
Other Significant Family History:
NO SIGNIFICANT FAMILY MEDICAL HISTORY
ADOPTED / FAMILY HISTORY UNKNOWN
SOCIAL HISTORY
How many servings of caffeine do you have per day (cup of coffee, tea, soda, energy drinks, etc.)?
NONE
Occasional
1
2
3
4
5+
Current (every day)
Never
What is your smoking status?
Current (some days)
Current Status Unknown
Previous
Unknown if ever smoked
If you smoke, how many packs per day?
<1
1
1 1/2
2
>2
How many servings of alcohol do you have per week?
NONE
Occasional
1-4
5-7
8-14
15-21
22+
What type(s) of illicit drugs do you consume?
Marijuana
None
Cocaine / Methamphetamine
In the past
Heroin
Illicit Prescription
Other (Please Specify)
WOMEN'S HISTORY
Number
Letter
Bra size:
26
28
30
32
34
36
38
40
42
44
46
48
50+
A
AA
AAA
B
C
D
DD
DDD
E
EE
F
G
other
Month
Day
Year
Last menstrual period:
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
Age at first period:
n/a
<10
10
11
12
13
14
15
16+
Month
Year
Date of last pap smear:
January
February
March
April
May
June
July
August
September
October
November
December
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
Method(s) of contraception:
Depo-Provera
Pill
NONE
Foam
Rhythm
Abstinence
Hysterectomy
Tubal Sterilization
Condom
IUD
Vasectomy
Other (please specify):
Are you pregnant?
Yes
No
Month
Year
Pregnancy due date:
January
February
March
April
May
June
July
August
September
October
November
December
Are you breastfeeding?
Yes
No
Age at first pregnancy:
n/a
<16
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50+
Age at first live birth:
n/a
<16
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50+
Age at menopause:
n/a
<20
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50+
Do you have a history of hormone replacement therapy?
Yes
No
SURGICAL HISTORY
Please indicate if the patient has had any of the following surgeries:
I HAVE HAD NO SURGERIES
Detached Retina
Ovary Removal
Appendectomy
Gallbladder Surgery
Pacemaker
Back Surgery
Heart Surgery
Prostate Surgery
Breast Biopsy
Hemorrhoid Surgery
Splenectomy
Breast Implants
Hysterectomy
Stomach Resection
Cataract Surgery
Inguinal Hernia
Thyroidectomy
Colon Surgery
Lumpectomy
Tonsillectomy
C-Section
Mastectomy
Umbilical Hernia
Other (please specify):
OTHER MEDICAL CONDITIONS AND DIAGNOSES
Please indicate if the patient has had any of the following conditions:
Anesthesia Complications
History of Blood Clots
Pacemaker
Arthritis
Heart Disease
Past Heart Attack
Asthma
Hepatitis
Seizures
Atrial Fibrillation
Herpes
Sickle Cell Anemia
Bleeding Disorder
High Blood Pressure
Sexually Transmitted Disease (STD)
Chest Pain
History of Cancer (please specify):
Stroke
Congestive Heart Failure
Transient Ischemic Attack (TIA)
Chronic Lung Disease (COPD)
HIV Positive
High Cholesterol (Hypercholesterolemia)
Diabetes Mellitus
Hyperthyroidism (High)
Gastroesophageal Reflux Disease (GERD)
Hypothyroidism (Low)
NONE
Other (please specify):
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Form Number 393
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