Patient Medical Information Check In Sheet - Aoa Arizona

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Patient Medical Information
Check in Sheet
Date_____
____________
Name
__________________________________
SS# __________________________
DOB _____________
(Last, First, M.I.)
Height:
________feet __________inches
Contraception
Bleeding
Paps
Breast Care
What is your current form of birth control?
When was your last period?
Date of your last
Date of your last
______________________
pap_____________
mammogram
Condoms?
Yes No
Number of days between periods?
_______________________
Normal
Abnormal
Sterilization Male
Female
______________________
Have you ever had an abnormal
Normal
Abnormal
IUD Yes No
Number of days of flow?
Do perform self-breast
pap Yes No
If yes, what type?________________
____________
exams?
Yes No monthly
Treatment? Yes No
Birth Control Pills? Yes No
Heavy? Yes No
occasionally
If yes, type
If yes, what type?________________
Are your periods regular? Yes No
LEEP Date __________
Injection? Yes No
Do you have pain with your periods?
If yes, what type?________________
Laser Date __________
Yes No
Other?________________________
Cryotherapy Date __________
Do you have bleeding in between
Other ?______________
your periods? Yes No
What is your reason for today’s visit?_
________________________________________________________________________________
Smoker? Yes No
Are you allergic to any medications? Yes No
What medications are you currently taking? None If yes, list with
If Yes, which one(s)?__________
______________________
dosage_____________________________________________________
___________________________________________________________
What type of reaction?_____________________________________
___________________________________________________________
Family History
Adopted No significant family history
Has any blood relative ever had any of the following:
Age
at
Disease
Deceased
Who in relationship to you
Maternal
Paternal
diagnosis
Maternal
Paternal
Yes No
Yes No Breast Cancer
Maternal
Paternal
Yes No
Yes No Ovarian Cancer
Maternal
Paternal
Yes No
Yes No Colon Cancer
Maternal
Paternal
Yes No Osteoporosis
Yes No
Maternal
Paternal
Yes No Stroke
Yes No
Maternal
Paternal
Yes No High Blood Pressure
Yes No
Maternal
Paternal
Yes No Heart Attack
Yes No
Maternal
Paternal
Yes No Diabetes
Yes No
Maternal
Paternal
Yes No
Yes No Blood Clots
Other:
Maternal
Paternal
Yes No
Surgeries
Cosmetic Surgeries?
Past Birth Control
Yes (include below) No
No prior surgeries
Type
Year
Type
Years used

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