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Signature OB/GYN A Community Specialty Practice of Johns Hopkins Medicine New Patient Worksheet for GYN exam Name: Date: 1. The reason for your upcoming visit: ___ Well Woman Visit ___ Problem Visit ___ Pre or Post-Op Visit ___ Procedure ___Post Partum ___ Other 2. Are there GYN problems that need attention? ___ yes ___ no If yes explain. THERE MAY BE A SEPARATE CHARGE ADDED FOR A PROBLEM. 3. Check if one of the following applies to you: ____ I have started/completed the Gardasil (HPV) vaccine series (women age 26 years or less) ____ I am menopausal (no period for 1 year or more). ____ I have had a hysterectomy or an endometrium ablation. ____ I am on birth control that suppresses my period. 4. Are you sexually active? ___never ___ yes ___ no 5. Do you have sex with: ___ men ___ women ___ both 6. Would you like to have a HIV test? ___ yes ___ no 7. Would you like STI testing? (Sexually transmitted infection) ___ yes ___ no 8. Do you need contraception? ___ yes ___ no 9. Who is your primary care physician? * IF YOU ARE HERE FOR A PROBLEM VISIT, PLEASE COMPLETE BOTH SIDES OF FORM. DO NOT WRITE BELOW IN THIS BOX. FOR OFFICE USE ONLY. LMP: ____________________________ Age: Last Pap: BP: / Last Mammogram: Physician’s Signature: Weight: Height: Parity: U/A: Allergies: Date: Last revision: 02/18/2015 Welcome to Signature OB/GYN PLEASE COMPLETE THIS SIDE, IF YOU ARE HERE FOR A PRE-OP OR PROBLEM VISIT Name: If you were referred by another physician, please indicate their name: Please circle only those conditions that are current or ongoing problems: FOR BOTH PROBLEM VISITS AND PRE-OP VISITS: Fever Headaches, Dizziness, Lightheadedness Sinus congestion Irregular Heartbeat, Chest Pain Cough, Shortness of Breath Nausea, Vomiting, Diarrhea, Constipation Urinary frequency, urgency, burning Unexplained easy bleeding, easy bruising, History of blood transfusion Anxiety, Depression, Psychiatric admission Skin rash, Piercings (other than ears) No symptoms or problems. Review of systems is negative. PRE-OP PATIENTS ONLY: Sleep apnea Problems with anesthesia excluding vomiting Recent Dental problems Recent use of ANY of the following medications: Weight loss products Blood thinners, such as Warfarin, Plavix, or Pradaxa St.John’s Wort Phentermine Ibuprofen, Aleve, or similar medications Aspirin Ma Haung Tenuate Lithium Last revision: 02/18/2015