Adams
P atterson
G ynecology
&
O bstetrics
A
D IVISION
O F
W OMEN’S
C ARE
C ENTER
O F
M EMPHIS
P atient
I ntake
Q uestionnaire
Name____________________________
D ate____________
A ccount#_________________
Age____________
R eason
f or
v isit_________________________________Date
o f
l ast
p eriod:_____________
Are
y ou
h aving
a ny
s ymptoms
t hat
a re
c urrently
b othering
y ou?______________________________________
I f
using
a ny
t ype
o f
b irth,
c ontrol
p lease
l ist
i t
h ere:
_ ____________
Please
l ist
a ny
a llergies
t o
m edications
o r
a ny
o ther
t hings.__________________________________________
W hat
is
t he
t otal
n umber
o f
p regnancies
y ou
h ave
h ad?_______
M iscarriages?_______
L iving
c hildren?_____
How
m any
v aginal
b irths?_______
How
m ay
C -‐sections?
_ _________
Largest
b irth
w eight?
_ _________
P referred
P harmacy
N ame
a nd
P hone
#
o r
a ddress___________________
If
y ou
h ave
p reviously
h ad
a ny
o f
t he
f ollowing
t est,
p lease
i nsert
t he
a pproximate
d ate
o f
t he
m ost
r ecent
t est
i f
k nown:
Test
Date
Result
Pap
Normal
□
A bnormal
□
Mammogram
Normal
□
A bnormal
□
Bone
D ensity
Normal
□
A bnormal
□
Other
Normal
□
A bnormal
□
Have
y ou
h ad
a ny
g ynecological
p roblems
i n
t he
p ast?
I f
y es,
p lease
l ist.
Yes
□
N o
□
Have
y ou
h ad
a ny
a bnormal
p ap
s mears
b efore?
L ist
a ny
t reatments.
Yes
□
N o
□
Have
y ou
h ad
a ny
s urgery
o n
t he
u terus,
o varies,
t ubes,
c ervix
o r
g enital
a rea?
P lease
l ist.
Yes
□
N o
□
Have
y ou
h ad
a ny
c omplications
d uring
p regnancy?
P lease
l ist
Yes
□
N o
□
Please
c heck
a ny
o f
t he
f ollow
c onditions
t hat
y ou
o r
a
c lose
f amily
m ember
m ay
h ave
h ad:
Personal
Family
Personal
Family
Condition
Condition
History
History
History
History
Heart
d isease
Blood
c lots
i n
l egs
o r
l ungs
Hypertension
Stroke
Diabetes
Genetic
p roblems
Autoimmune
D isease
Birth
D efects
Stomach
u lcer
o r
R eflux
Thyroid
p roblems
Hepatitis/Liver
D isease
Breast
o r
O varian
C ancer
Infertility
Colon
C ancer
Asthma
Any
C ancer,
T ype_________
Anxiety
STD,
T ype______________
Depression
Surgery,
T ype____________
PMS
Neurologic
p roblems
Migraine
h eadaches
Blood
C lotting
d isorders
Urinary
Bleeding
d isorders
High
C holesterol
Osteopenia
o r
o steoporosis
Kidney
p roblems
Other__________________
Comments:
R ev
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