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WOMEN’S INTAKE FORM AND HEALTH QUESTIONNAIRE KAREN LAFACE, MD PATIENT NAME:_______________________________________________ TODAY’S DATE: ________________ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Your answers on this form will help your provider better understand your medical concerns and conditions. If you are uncomfortable with any question, do not feel you need to answer it. If you do not remember details, please approximate. Add any notes you feel are important. ALL QUESTIONS ARE OPTIONAL AND WILL BE KEPT CONFIDENTIAL. Main reason for your visit today:___________________________________________________________________________________ ALLERGIES List anything that you are allergic to, including medications, foods, animals, insects, etc, and how each affects you. 1.___________________________________________________________________________________________________________ 2.___________________________________________________________________________________________________________ 3.___________________________________________________________________________________________________________ 4.___________________________________________________________________________________________________________ 5.___________________________________________________________________________________________________________ 6.___________________________________________________________________________________________________________ 7.___________________________________________________________________________________________________________ 8.___________________________________________________________________________________________________________ FAVORITE PHARMACY Local:_______________________________________________________________________________________________________ Mail Order:___________________________________________________________________________________________________ MEDICATIONS: please list all of your medicines, including over the counter medication, herbs, supplements, minerals, remedies, etc. If you have a typed list to give to us, you don’t need to fill this out. Please also note the last time you took it. DRUG NAME STRENGTH FREQUENCY 1.___________________________________________________________________________________________________________ 2.___________________________________________________________________________________________________________ 3.___________________________________________________________________________________________________________ 4.___________________________________________________________________________________________________________ 5.___________________________________________________________________________________________________________ 6.___________________________________________________________________________________________________________ 7.___________________________________________________________________________________________________________ 8.___________________________________________________________________________________________________________ 9.___________________________________________________________________________________________________________ 10.__________________________________________________________________________________________________________ 11.__________________________________________________________________________________________________________ 12.__________________________________________________________________________________________________________ IMMUNIZATION HISTORY: type and dates (if you have a copy of your vaccination records to share, don’t complete this section) Chickenpox___________________________________________________________________________________________________ Flu shot______________________________________________________________________________________________________ Gardasil/HPV__________________________________________________________________________________________________ Hepatitis B____________________________________________________________________________________________________ Hepatitis A____________________________________________________________________________________________________ Meningococcus________________________________________________________________________________________________ MMR (measles, mumps, rubella)___________________________________________________________________________________ Pneumonia___________________________________________________________________________________________________ Tdap (tetanus, diphtheria and pertussis)_____________________________________________________________________________ Tetanus______________________________________________________________________________________________________ Polio_________________________________________________________________________________________________________ Zostavax (shingles)_____________________________________________________________________________________________ Other________________________________________________________________________________________________________ Name:________________________________________________Date:_______________________ PAST MEDICAL HISTORY: PLEASE CHECK ALL THAT APPLY o o o o o o o o o o o o ANXIETY ARTHRITIS ASTHMA ALLERGIES BLEEDING DISORDER BLOOD CLOTS CANCER DIVERTICULITIS FIBROMYALGIA GOUT HEART DISEASE DIABETES DIALYSIS o o o o o o o o o o o o HEART ATTACK PACEMAKER HEART MURMUR HEART FAILURE REFLUX DISEASE HIV OR AIDS HIGH BLOOD PRESSURE THYROID PROBLEMS KIDNEY DISEASE KIDNEY STONES SKIN PROBLEMS LIVER DISEASE o o o o o o o OSTEOPOROSIS MENOPAUSE LUNG PROBLEMS STROKE TUBERCULOSIS PNEUMONIA OTHER _______________________________ _______________________________ _______________________________ _______________________________ SEXUAL HISTORY AND WOMEN’S HEALTH HISTORY Last PAP smear and result_______________________________________________________________________________________ Last mammogram and result______________________________________________________________________________________ Are you sexually active?_________________________________________________________________________________________ Gender of you current sexual partner?______________________________________________________________________________ Number of partners in the last 12 months?___________________________________________________________________________ Number of partners in your lifetime?________________________________________________________________________________ Have you ever had a sexually transmitted disease?____________________________________________________________________ Have you been tested for sexually transmitted diseases, including HIV or AIDS?_____________________________________________ PAST SURGICAL HISTORY 1.___________________________________________________________________________________________________________ 2.___________________________________________________________________________________________________________ 3.___________________________________________________________________________________________________________ 4.___________________________________________________________________________________________________________ 5.___________________________________________________________________________________________________________ 6.___________________________________________________________________________________________________________ FAMILY HEALTH HISTORY RELATION ALIVE? AGE SIGNIFICANT HEALTH PROBLEMS Mother Y/N ____ ___________________________________________________ Father Y/N ____ ___________________________________________________ Sister Y/N ____ ___________________________________________________ Sister Y/N ____ ___________________________________________________ Brother Y/N ____ ___________________________________________________ Brother Y/N ____ ___________________________________________________ Maternal Grandmother Y/N ____ ___________________________________________________ Paternal Grandmother Y/N ____ ___________________________________________________ Maternal Grandfather Y/N ____ ___________________________________________________ Paternal Grandfather Y/N ____ ___________________________________________________ Name:_______________________________________Date:___________________________________ SOCIAL HISTORY Education_____________________________________________________________________________________________________ Occupation___________________________________________________________________________________________________ Marital Status__________________________________________________________________________________________________ Do you live alone or with someone?________________________________________________________________________________ Pets_________________________________________________________________________________________________________ Hobbies or important interests_____________________________________________________________________________________ How much alcohol do you drink?___________________________________________________________________________________ Drug use: recreational or street drugs?______________________________________________________________________________ REVIEW OF SYMPTOMS (PLEASE ELABORATE IF YOU HAVE EXPERIENCED THESE PROBLEMS) ALLERGIC OR IMMUNOLOGIC o Sneezing o Hives o Runny nose CARDIOVASCULAR o Chest pain or heaviness o Palpitations o Passing out CONSTITUTIONAL o Fatigue o Exercise intolerance o Fever o Weight gain o Weight loss EYE PROBLEMS o Dry o Irritated o Vision change o Last eye exam_______ EAR, NOSE AND THROAT o Hearing problems o Gums o Teeth o Mouth sores o Nosebleeds o Hoarseness GASTROINTESTINAL o Stomach pain o Bleeding or ulcers o Celiac disease o Change in stools o Blood in stool o Vomiting o other URINARY o Blood in urine o Infections o Loss of urine HEMATOLOGIC o Bruising or bleeding o Swollen glands SKIN o o o o o o o Moles Sores Dry skin Eczema Growths Itching Other MUSCULAR o Back pain or joint pain o Muscle aches or weakness NEUROLOGIC o Dizzy o Fainting o Headaches o Migraines o Memory loss o Numbness o Weakness o MS o Restless legs o Night cramps o Seizures PSYCHIATRIC o Alcohol overuse o Anxiety or stress o Depression o Do not feel safe o Mania o Sleep issues LUNG PROBLEMS o Coughing o Coughing blood o Short of breath o Asthma o COPD o Snoring o Sleep apnea o Wheezing PLEASE ELABORATE ON ANY OF THESE ISSUES IN THE SPACE BELOW: _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Name:____________________________________Date:__________________________ To help your doctor during today’s health exam, please complete items 1 through 11. 1. Age: ______ First year of menstruation:_____________ First day of last period or age at menopause: ______ 2. Number of times pregnant: ______ Number of completed pregnancies: ______ f. Change in size/firmness of stools • YES • NO g. Change in size/color of a mole • YES • NO h. Severe headaches • YES • NO i. Pain in the leg, chest, abdomen or joints • YES • NO j. Trouble falling or staying asleep • YES • NO k. Often feeling down, depressed or hopeless during the past month • YES • NO l. Often having little interest or pleasure in doing things during the past month • YES • NO m. Conflict in your family or relationships, sometimes handled by pushing, hitting or cruelty • YES • NO Date of last pregnancy: ______ If you are under age 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? • YES • NO 3. If you are through menopause or over age 50, do you take any of the following pills? Calcium Estrogen Progesterone • YES • NO • YES • NO • YES • NO 4. Have you had any of the following problems: a. Abnormal Pap smears • YES • NO If yes, date: __________ problem: _________________ For abnormality, did you have any of the following done: Colposcopy • YES • NO Biopsies • YES • NO Surgery • YES • NO 6. Do you have a parent, brother or sister with a history of the following: a. Cancer of the breast, intestine or female organs • YES • NO b. Heart pain or heart attacks before the age of 55 • YES • NO If yes to a or b: Relation: __________________ Type: _______________ Relation: __________________ Type: _______________ 7. Osteoporosis (thin-bone) screening: b. High blood pressure, heart disease or high cholesterol • YES • NO c. Migraine headaches, blood clot in legs or cancer • YES • NO d. Abdominal or pelvic surgery or special tests • YES • NO a. Is there a history of any • YES • NO relatives with the following: stooping over or losing height as they got older, "thin bones," hip fractures If yes, relation: _________________________ b. Have you had any of the following: If yes, what: ___________________ when: _________ Height loss • YES • NO Broken hip or wrist • YES • NO Bone-density test • YES • NO 5. Do you have any of the following: a. Problems with present method of birth control • YES • NO b. Bleeding between periods or since periods stopped • YES • NO c. Pain with intercourse or periods • YES • NO d. Any problem with interest in or enjoying intercourse • YES • NO e. New or enlarging breast lump • YES • NO c. Do you take any of the following: Steroids (prednisone) • YES • NO Medication for thyroid, seizures or thin bones • YES • NO Form continues on next page > Name:______________________Date:__________________ 8. Have you ever used tobacco? • YES • NO h. Have you ever had a mammogram? • YES • NO If yes: Average number of packs/day:_____ If yes, date of last: _______ where:________________ Number of years smoked:______ Have you ever had any abnormal mammograms? • N/A • YES • NO Year quit:______________ If yes, date: ________ problem: __________________ When are you planning to quit? For abnormality, did you have any of the following: • now • next 6 months • sometime • never 9. Do you drink alcohol? • YES • NO Biopsy Cyst fluid drained Surgery • YES • NO • YES • NO • YES • NO If yes: a. Have you ever felt you should cut down on your drinking? • YES • NO i. When is the last time you had a dental check-up?________ j. Do you take Vitamin D? ______ b. Have people ever annoyed you • YES • NO by nagging you about your drinking? c. Have you ever felt guilty about your drinking? • YES • NO d. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? • YES • NO l. Do you meditate, do yoga, or participate in any form of relaxation? ___________ m. Are spirituality or religion part of your life? __________ 10. Prevention: a. Which of the following are included in your diet: Grains and starches Vegetables Dairy foods Meats Sweets k. Do you take any other vitamins, herbs, supplements or natural remedies? _________ • a lot • a lot • a lot • a lot • a lot • some • some • some • some • some • few • few • few • few • few b. Exercise: Activity _______________________________________ Days per week ________ 11. Please describe any other concerns you have: _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Time/duration ________ minutes Thank you for your help. Exertion: • stroll • mild c. Do you always wear seat belts? • heavy • YES • NO d. If over 30 years old, have you N/A • YES • NO had your cholesterol level checked in the past five years? e. Have you had a tetanus shot in the past 10 years? • YES • NO f. Does your house have a working smoke detector? • YES • NO g. Do you have firearms at home? • YES • NO