Download Well-woman exam - Karen LaFace, MD

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:
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
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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