General Medicine Clinic: Dr C Osuji

Concerns patient wishes to bring up for annual visit Menstrual/ bleeding concerns Other reproductive health concerns Has a PCP Name of PCP Months since last visited PCP Month and year of last Pap smear Birth control methods patient is using How often uses condoms during sex Weeks since last Depo-Provera shot Type of IUD Planning pregnancy in next 12 months Mental health concerns Fitness activities Descriptiion of diet and any nutritional concerns

Medical History

RECENT MEDICAL AND SURGICAL HISTORY

Recent medical problems Recent surgeries

SOCIAL HISTORY

Patient has sex with men, women, or both Type of sex Number of sexual partners in past year Number of sexual partners in lifetime Other social history behaviors Drinks per typical week Drank 5 or more drinks on any one occasion in the past month CAGE Questions Forms of tobacco smoked Years of tobacco smoking Cigars per week Frequency of pipe smoking Recreational drugs used History of Intravenous drug use Intravenous drug use in past year

MEDICATIONS, SUPPLEMENTS,CAM

Regularly taking or using medications Medications taken Regularly taking supplements Supplements taken Types of complementary and alternative medicine used

ALLERGIES

Allergic to medications Medication allergies

REVIEW OF SYSTEMS

ROS - General ROS - Eyes ROS - ENT ROS - Respiratory Cough is productive ROS - Cardiovascular and breast ROS - Gastrointestinal Appearance of vomit ROS - Genitourinary (female) ROS - Hematologic/ lymphatic ROS - Musculoskeletal ROS - Neurologic ROS - Psychiatric ROS - Skin ROS - Allergic/ Immunologic Anything else patient would like to share

Update your insurance information by logging into your portal account and going to 'MY PROFILE' on top right corner. (We may need copies, which can be sent by messaging us)