Patient Encounter Form

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DATE:________
RETURN PATIENT ENCOUNTER FORM
OFFICE USE ONLY
Date Initial Visit:________
Referring Physician:______________________
PCP Physician______________________
Other CC's:
______________________
___________________________________
______________________
___________________________________
TO BE COMPLETED BY PATIENT
1. Reason / condition for your visit today:__________________________________
2. Have you had any changes in your health history since your previous visit?:
Medical Conditions?:__________________________________________________________
Surgeries / Date:______________________________________________________________
Medication(s) /Dosage:_________________________________________________________
Allergies: ___________________________________________________________________
Reproductive History?: _____________________________________________________
At what age was your 1st menstrual period?______When was your last menstrual period?_______
Have you used birth control pills?______What type?_______for how long?___________
Has hormone therapy ever been prescribed?________If yes, what type?__________________
How many full term labors have you had?_______ Did you breast feed?__________________
Have you had premature births?____________ Have you had any miscarriages?_____________
3. Have you had any changes in your social history since your previous visit?:
Marital Status: Single
Divorced
Married
Widow
Current Occupation/Employer:_____________________________________________
Do You smoke: _____________ How many packs a day? ______________________
Do you drink alcohol?___________ How many drinks a day?__________________
4. Have you had any changes in your family health status since your previous visit? :
Mother: ____________________________ Father:____________________________________
Brothers:_________________________________
Sisters:____________________________________
Family Illnesses: (Please identify relative(s) with cancer).
Breast cancer?
Colon cancer?
Uterine cancer?
Ovarian Cancer?
Diabetes?
Hypertension?
Office Use PFS: 1=pertinent
2=complete (established pt)
3=complete (new pt)
1

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