Jan Patterson

Patient Information

First Name * Last Name * Date of Birth * Referring Physician Name Referring Physician Phone Referring Physician Address Primary Care Physician Reason for visiting Gianna: How did you hear about us?

Pharmacy Information

Name Phone Number Address or Cross Streets

Past Medical History

Please select the box if you have had one of these:

Past Surgical History

List Year/Surgery

Hospitalizations

If you have been hospitalized for any reason (excluding surgeries listed above and deliveries), please describe here:

Medications

Please list your current medications, including vitamins and herbs, and their respective doses:

Allergies

Please list any allergies to medications (or latex) that you may have:

Family Planning History

Please check all that you have taken or used: Are you currently sexually active? Have you ever fathered a child?

Family History

Has anyone in your family had the following:

If you chose any of the previous options, please describe the condition and the family member's relationship to you:

Social History

Occupation or Training: Marital Status If married, number of years married: Exercise type and frequency: Caffeine Intake: Dairy Intake: Fruits and Vegetables: Gluten Intake:

Have you used any of the following:

Alcohol Tobacco Recreational drugs

Health Maintenance

Have you ever had the following: Would you like to take an HIV test? Would you like to take a test for Hepatitis C?

Review of Systems

Check any of the following that you are CURRENTLY experiencing:

General Skin Head, Eyes, Ears, Nose, and Throat Breast Chest Cardiovascular Gastrointestinal Genitourinary Extremities Have you ever had a sexually transmitted infection?

Prior Fertility Testing

How long have you been trying to achieve? Prior Investigations Prior treatment?