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PERSONAL DATA
Marital Status
single
married
partnered
separated
divorced
widowed
WOMEN ONLY - OB/GYN HISTORY
Age period started
n/a
under 8
8
9
10
11
12
13
14
15
16
17
18
19
20
21+
Age period stopped
n/a
under 42
42
43
44
45
46
47
49
50
51
52
53
54
55+
Have you ever used contraceptives?
currently
in the past
never
Are you pregnant or possibly pregnant?
yes
no
Have you ever taken hormones?
currently
in the past
never
Do you have any of the following? (select all that apply.)
bleeding after intercourse
nipple discharge
vaginal itching
bleeding between periods
prolonged, excessive periods
vaginal sores
breast lump
vaginal discharge
PREGNANCY HISTORY
Number of pregnancies
0
1
2
3
4
5
6
7+
Number of live births
1
2
3
4
5
6
7+
Number of stillbirths
1
2
3
4
5
6
7+
Number of C-sections
1
2
3
4
5
6
7+
Number of miscarriages
1
2
3
4
5
6
7+
Number of abortions
1
2
3
4
5
6
7+
Number of premature births
0
1
2
3
4
5
6
7+
ALLERGIES
Do you have any
medication
allergies?
yes
no
Amoxicillin
Lortab
Penicillin
Cephalosporins
Morphine
Sulfa
Codeine
NSAIDs (aspirin ibuprofen, etc.)
Tetracycline
Demerol
Oxycodone
Tylenol
Erythromycin
Do you have any
food
allergies?
yes
no
Eggs
MSG
Seafood
Fish
Nuts
Soy
Gluten
Peanuts
Wheat
Milk
Do you have any
environmental
allergies?
yes
no
Adhesive Tape
Dust Mites
Mold
Animal Dander
Iodine
Pollen
Bee Stings
Latex
Seasonal Allergies
(Ragweed)
Medical History
Do you have any current medical problems?
yes
no
Have you had any medical problems in the past?
yes
no
ADD
Currently
In The Past
Anemia
Currently
In The Past
Anesthetic Complications
Currently
In The Past
Anxiety
Currently
In The Past
Asthma
Currently
In The Past
Bipolar
Currently
In The Past
Bladder Cancer
Currently
In The Past
Blood Clots
Currently
In The Past
Bone Cancer
Currently
In The Past
Breast Cancer
Currently
In The Past
Cataracts
Currently
In The Past
Cervical Cancer
Currently
In The Past
Chest Pain
Currently
In The Past
Colon Cancer
Currently
In The Past
Colon Polyps
Currently
In The Past
Depression
Currently
In The Past
Diabetes
Currently
In The Past
Emphysema / COPD
Currently
In The Past
Glaucoma
Currently
In The Past
Heart Attack
Currently
In The Past
Hepatitis B
Currently
In The Past
Hepatitis C
Currently
In The Past
High Blood Pressure
Currently
In The Past
High Cholesterol
Currently
In The Past
Irregular Heartbeat
Currently
In The Past
Kidney Stones
Currently
In The Past
Leukemia
Currently
In The Past
Liver Cancer
Currently
In The Past
Lung Cancer
Currently
In The Past
Lung Nodules
Currently
In The Past
Lymphoma
Currently
In The Past
Osteoarthritis
Currently
In The Past
Ovarian Cancer
Currently
In The Past
Overactive Thyroid
Currently
In The Past
Pancreatic Cancer
Currently
In The Past
Positive TB Skin Test
Currently
In The Past
Prostate Cancer
Currently
In The Past
Schizophrenia
Currently
In The Past
Skin Cancer
Currently
In The Past
Stroke
Currently
In The Past
Thyroid Cancer
Currently
In The Past
Thyroid Nodules
Currently
In The Past
Ulcers
Currently
In The Past
Underactive Thyroid
Currently
In The Past
Uterine Cancer
Currently
In The Past
Family History
Do you have any family medical conditions?
yes
no
Are you adopted?
yes
no
Father
Mother
Brother
Sister
Son
Daughter
Anesthetic Complications
High Blood Pressure
Diabetes
Chest Pain
Heart Attack
Irregular Heartbeat
High Cholesterol
Blood Clots
Anemia
Stroke
Emphysema / COPD
Asthma
Lung Nodules
Hepatitis B
Hepatitis C
Thyroid Nodules
Underactive Thyroid
Overactive Thyroid
Osteoarthritis
Kidney Stones
Ulcers
Cataracts
Glaucoma
Positive TB Skin Test
Anxiety
Bipolar
Schizophrenia
Depression
ADD
Colon Polyps
Colon Cancer
Bladder Cancer
Skin Cancer
Breast Cancer
Lung Cancer
Pancreatic Cancer
Liver Cancer
Lymphoma
Leukemia
Thyroid Cancer
Prostate Cancer
Cervical Cancer
Ovarian Cancer
Uterine Cancer
Bone Cancer
SURGICAL HISTORY
Have you had any Surgeries?
yes
no
Please provide DATE.
Appendectomy
DATE
Tonsillectomy
DATE
Gallbladder Removed
DATE
Hysterectomy
DATE
Heart Bypass Surgery
DATE
Hemorrhoids Removed
DATE
Ovaries Removed
DATE
Spleen Removed
DATE
Colostomy
DATE
Pacemaker
DATE
Defibrillator
DATE
Coronary Artery Stent
DATE
Colon Removal Partial
DATE
Colon Removal Total
DATE
Hernia Repair Abdominal
DATE
Hernia Repair Belly Button
DATE
Hernia Repair Incisional
DATE
Cataract
Left
Right
Both
DATE
Mastectomy
Left
Right
Both
DATE
Groin Hernia Repair
Left
Right
Both
DATE
HEALTH MAINTENANCE PLAN
Please indicate when you last had each of the following applicable tests
1 year ago or less
2 years ago
3 years ago
4 years ago
5 years ago
6 years ago
7 years ago
8 years ago
9 years ago
10 or more years ago
Colonoscopy
Colon Polyp Removal
DEXA Scan
Diabetic Eye Exam
Mammogram
Prostate Exam
(with PSA)
SOCIAL HISTORY
TOBACCO
What is your smoking status?
current (every day)
previous
current (some days)
never
Amount of packs per day smoked?
less than 1
1-2
more than 2
less than 5
5
10
15
20
25
30
35
40+
How many years have you smoked?
less than 5
5
10
15
20
25
30
35
40+
How many years ago did you quit?
Do you have a desire to quit?
yes
no
Are you exposed to secondhand smoke?
yes
no
ALCOHOL
Do you consume alcohol?
currently
in the past
never
How much did you drink?
up to 3 times per week
daily
less than once per week
4-6 times per week
social occasions
less than 5
5
10
15
20
25
30
35
40+
How many years ago did you quit?
Have you ever felt you should cut down on your drinking?
yes
no
Have people annoyed you by criticizing your drinking?
yes
no
Have you ever felt bad or guilty about your drinking?
yes
no
Have you ever had a drink first thing in the morning
to steady your nerves or get rid of a hangover?
yes
no
DRUGS
Have you used recreational drugs?
currently
in the past
never
How much?
daily
up to 3 times per week
4-6 times per week
less than once per week
less than 5
5
10
15
20
25
30
35
40+
How many years ago did you quit?
CAFFEINE
Do you drink caffeinated beverages?
currently
in the past
never
How much do you drink?
daily
up to 3 times per week
4-6 times per week
less than once per week
EXERCISE
Do you exercise regularly?
currently
in the past
never
How much?
daily
up to 3 times per week
4-6 times per week
less than once per week
TRAVEL
Have you recently traveled outside of the country?
no
yes
Do you live in more than one location throughout the year?
no
yes
If yes, please remember to provide us with alternate contact and provider information.
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