New Obstetrical Patient Information Form Page 4

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J
A. G
, MD
UDITH
URDIAN
M
S
, MD
ICHELLE
PECTOR
P
E. S
, PA-C
ATRICIA
HEVOCK
M
T
-H
, CNM
ELANIE
HORNTON
UYCKE
Have you ever had any of the following other surgeries? (Please check all that apply)
____ Appendectomy
____ Cardiac
____ Hernia
____ Other Abdominal
____ Breast Augmentation
____ Breast Biopsy
____ Breast Lumpectomy
____ Breast Mastectomy
____ Breast Reduction
____ Orthopedic
____ Cholecystectomy (Removal of Gall Bladder)
Other (describe) _____________________________________________________________________________________________
YOU
ANYONE IN YOUR FAMILY
Have
or
had the following diseases? If yes, whom and age at diagnosis?
(Please check all that apply and describe further)
____ Breast Cancer________________________________________________________________________________
____ Ovarian Cancer _______________________________________________________________________________
____ Both Breast and Ovarian Cancers in one family member ______________________________________________
____ 2 or More Breast Cancers on One Side of the Family or in an Individual __________________________________
____ Male Breast Cancer ___________________________________________________________________________
____ Ashkenazi Jewish with Breast or Ovarian Cancer ____________________________________________________
____ Uterine Cancer _______________________________________________________________________________
____ Endometrial Cancer ___________________________________________________________________________
____ Colorectal Cancer_____________________________________________________________________________
____ Pancreatic Cancer ____________________________________________________________________________
____ Stomach Cancer ______________________________________________________________________________
____ Brain Cancer _________________________________________________________________________________
____ Heart Disease ________________________________________________________________________________
____ Diabetes ____________________________________________________________________________________
____ Stroke ______________________________________________________________________________________
____ Asthma _____________________________________________________________________________________
____ Anemia _____________________________________________________________________________________
____ Kidney Disease _______________________________________________________________________________
____ High Cholesterol _____________________________________________________________________________
Healthcare for w om en, by w om en…
9711 Medical Center Drive, Suite 109, Rockville, MD 20850
|
301.762.5501
|
Fax 301.309.8727
4

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