New Patient Health History Form Page 4

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Medicine In Balance
New Patient Health History Form
Women Only
Last Menstrual Period ____ ___ ___ ___
Have you ever been pregnant?
Yes [ ] No [ ]
If so, age of first delivery _______ # of pregnancies _____ # of deliveries _____
Method of Contraception ______________
Last pap: ______________
Have you ever had an abnormal pap?
Yes [ ] No [ ]
Have you had a mammogram?
Yes [ ] No [ ]
If so, when _________
Was it normal
Yes [ ] No [ ]
Have you ever had a bone-density test (Dexa scan)?
Yes [ ] No [ ]
If so, when _________
Was it normal [ ] borderline [ ] low [ ]
Men Only
Have you had a Prostate test (PSA) done?,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Yes [ ] No [ ]
What were the results? ________________
Summary
What i s yo ur pr ima ry g oal for our wor k toget her? ______________________________________________
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Addition al Comments
______________________________________________________________________________________________
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Signat ure
__ ___ ____ ___ ___ ___ ____ ___ ___ ___ _ ____
Date
_ ____ ___ ____ ___ ___ ___ ____ _
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