Jan Patterson

Patient Information

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

Pharmacy Information

Name Phone Number Address or Cross Streets

Allergies

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

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Medications

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

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Gynecological History

What is your height? What is your weight? Last menstrual period: Age when periods began: Nature of cycles: Average length of menstrual flow: Length of cycle: Have you ever charted your cycles?

Gynecological Review of Systems

Do you have abnormal bleeding? . How many days of brown spotting do you have at the end of your flow? How many days of very light bleeding do you have before the first day of heavy flow? Do you have painful periods or cramps? Do you have other pain? How severe are your premenstrual symptoms? Please check any of the following symptoms if you notice them MORE THAN 3 DAYS before your period: . How many days do you have these symptoms? Do you have: Do you have: Have you ever had a sexually transmitted infection? . Number of lifetime sexual parters:

Prior Fertility Testing

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

Family Planning History

Please check all that you have taken or used: details

Pregnancy History

Number of Pregnancies Number of Full Term Pregnancies Number of Premature Deliveries Number of Abortions Number of Miscarriages Number of Live Children Details of pregnancies

Gynecological Health Maintenance

Most recent pap smear and its result: Have you ever had an abnormal result? If yes, please explain. Have you ever had the following: . Are you currently sexually active?

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 (example: Maternal grandmother - breast cancer ) :

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Social History

Are there any smokers in your home? Have you been exposed to chemicals or toxins? Have you been exposed to heavy metals? What is your highest level of education? What type of diet are you following? Explain your diet if applicable: Do you feel stressed (tense, restless, nervous, or anxious, or unable to sleep at night)? Please explain if applicable: Do you use your seatbelt regularly? Occupation or Training: Marital Status If married, number of years married: Exercise type and frequency: Fruits and Vegetables: Dairy Intake: Caffeine Intake:

Have you used any of the following:

Alcohol Tobacco Recreational drugs .

Health Maintenance

Have you ever had the following?

For each option chosen above, please enter the date each test was taken and its result below:

. Would you like to take an HIV test? Would you like to take a test for Hepatitis C? What is your gluten intake? Do you perform monthly self-breast exams? Who do you live with? Do you have exotic pets? Do you live with cats or exposure to litter? What are your hobbies? Do you have a nickel allergy?

Past Surgical History

Have you ever had cervical treatment? Have you ever had breast or gynecological surgery? Other surgery: list Year/Surgery

Review of Systems

Check any of the following that you are CURRENTLY experiencing:

General Skin Head, Eyes, Ears, Nose, and Throat Please explain if necessary: Breast Chest Cardiovascular Gastrointestinal Genitourinary Extremities

Past Medical History

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

Hospitalizations

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

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