Dr. Gerald B Harris, II

Patient Name * Date *

To help your doctor during today's health exam, please complete items 1 through 11.

Age * First day of last menstrual period (or first year of menstruation, if through menopause): Number of times pregnant Number of completed pregnancies Date of last pregnancy If you are under the age of 55, what method of birth control do you use? If pills, what kind? How many years have you used the pills? Are you planning a pregnancy in the next 6-12 months? If you are through menopause or over age 50, do you take any of the following pills? Abnormal Pap Smears If yes, date? Problem For abnormality, did you have any of the following done: Any of the following? Abdominal or Pelvic Surgery? If yes, what type of surgery and when? Do you have any of the following: Does you parent, brother or sister have history of the following:

Do you have any of the following:

Cancer of the breast, intestine or female organ Heart pain or heart attacks before the age of 55 Osteoporosis (thin-bone) screening Is there a history of any relatives with the following: stooping over or losing height as they got older, "thin bones" hip fractures If yes, relation: Have you had any of the following: Do you take any of the following: Have you ever used tobacco If yes, average number of packs/day: Number of years smoked Year quit When are you planning to quit Do you drink alcohol Have you ever felt you should cut down on your drinking Have people ever annoyed you by nagging on your drinking Have you ever felt guilty about your drinking Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover

Which of the following are included on your diet:

Grains and Starches Vegetables Dairy foods Meat Sweets Exercise/Activity Days per week Time/Duration in minutes Exertion: Do you always wear seatbelts If over 30 years old, have you had your cholesterol checked in the past five years Have you had a tetanus shot in the past 10 years Does your house have a working smoke detector Do you have firearms at home Have you ever had a mammogram If yes, date of last Have you ever had any abnormal mammograms If yes, date Problem For abnormality, did you have any of the following: How many sexual partners have you had in the past 12 months In your lifetime When is the last time you had a dental check up Please describe any concerns you have? Do you have a personal or family history of blood clots, blood disease or disorder?If yes, please explain Last Bone Density Scan Last Mammogram