New Patient Form (Ob/gyn)
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1
2Please complete the form and bring it with you to your appointment. Thank you.
Surgical History: (if hysterectomy or other gynecologic
Medical Problems (blood pressure, diabetes,
procedure, please list reason for surgery)
migraines, etc.):
Year:
Procedure:
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Social History:
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Tobacco:
never
quit, year ____
yes, __ pack(s) per day
Alcohol:
no
yes, __ drinks per day/week
Allergies to medications (specify reaction):
Illicit drug use:
no
yes, please list
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Medications (dose, frequency):
Family History: please list medical problems
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Mother: ______________________________________
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Father: _______________________________________
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Siblings: ______________________________________
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Children: _____________________________________
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List family members that have the following:
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Breast cancer: _______________________________
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Ovarian cancer: ______________________________
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Uterine cancer: ______________________________
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Colon cancer: ________________________________
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Osteoporosis:________________________________
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