Health Questionnaire

Please provide as much information as possible here to help us create your patient record. The more comprehensive your responses, the better we can serve your needs. When finished, click "submit history" at the bottom.

PATIENT INFORMATION

Name:

If you go by something other than your legal name, please indicate here:

Address: Apt./Condo #:

City: State: Zip:

Home Phone: Work Phone: Cell Phone:

Which number would like to be primary? Home PhoneWork Phone Cell Phone May we leave messages at this number? yes no

Email Address (required):

Date of Birth: Age: SSN#:

Sex at Birth: female male  Identify as: femaleneutralmale

Who are you seeing today?
Charles Downey, MD Dr. Meghan Drake Dr. Jolaiya Faturoti Wanda Orange, FNP

Insured (Name of Insurance Card Holder – Self, Spouse, Parent, etc.):

Insured's Date of Birth: Insured's SSN#:

Insured's Employer: Phone:

In case of an emergency notify: Phone:

Relationship to patient: Other Contact Phone:

Prescription Pharmacy Name: Phone:

Pharmacy address or closest intersection:

How did you hear about our office?

If referred to our office, by whom?

Your current Primary Care or Family Physician: Phone:

GYNECOLOGICAL HISTORY:

Reason for Visit:

Last Menstrual Cycle:

Date of last pap smear: Normal Abnormal  Where:

Have you ever had an abnormal Pap Smear?  No  Yes   If yes, year:

Treatment: Repeat Pap Colposcopy/Biospy Cryotherapy LEEP/Cone Other

If still having cycles: Length of Cycles: Days of flow:

Hysterectomy (If yes, year): Menopause (If yes, year)

Date of last mammogram:  Normal  Abnormal  Where?

Sexually Active: Yes Not Currently never

Sexual partners are: Male Female Both

Total number of male sexual partners in your life: 0 1-4 5-10 11-20 >20

Birth Control: Not Necessary None Condoms Pill/Patch/Ring Injection Tubal IUD Vasectomy
Implant Other

List methods of birth control or hormone replacement therapy you have used in the past:

Infections: Do you currently have or do you have a history of the following (please indicate year)
Chlamydia Gonorrhea Warts HPV Trichomonas Syphilis
Herpes (number of outbreaks per year:)

Are you interested in screening for sexually transmitted diseases (the charge for this test may apply to your insurance deductible)? Yes No

How old were you when you had your first menstrual cycle:

Any history of physical or sexual abuse / assault or concerns in your current relationship? yes no

OBSTETRICAL HISTORY

Not Applicable none

Number of Pregnancies: Number of Deliveries: Number of living children:

Date	Outcome (vaginal delivery, c/section, miscarriage, termination, ectopic

CURRENT MEDICATIONS

Not Applicable none

Medication	Date	Dosage Instructions	Diagnosis

Vitamins: None Calcium Multivitamin Vit B Vit C Vit E Vit A Iron   Others:

Over-the-counter medications:
Herbal / Natural Supplements:

MEDICAL HISTORY

Past Medical History: (Hypertension, Diabetes, Asthma, Injuries, Blood transfusion, etc.)   Not Applicable none

Diagnosis	Onset Date	Treating MD

Drug Allergies: (Sulfa, Penicillin, Myacins, etc.)   Not Applicable none

Drug	Reaction (Itching, Shortness of Breath, Hives, etc)

Are you allergic to any of the following: Iodine IV dye Peanuts Latex

SURGICAL HISTORY

(Hysterectomy, Gallbladder, Appendix, etc.)   Not Applicable none

Surgery	Date

FAMILY HISTORY

Mother: alive deceased  Present Health or Cause of Death:

Father: alive deceased  Present Health or Cause of Death:

SOCIAL HISTORY

Smoker: no yes   pack(s) per day for years

Past Smoker: no yes   pack(s) per day for years year quit

Alcohol: no yes   servings every week

Drug Use: no yes   type and frequency

Occupation:

Education: High School College Graduate School   Other:

Marital Status: Single Engaged Married Widowed Separated Divorced Significant Other

Live with: Alone Roommate Family Spouse Fiancé SignificantOther

Type Of Diet: Regular Low Fat / Carbohydrate / Cholestrol Diabetic Vegetarian Other

Caffeine: no yes   servings per day

Exercise: no yes   Type: Cardio Weights   Other: # days/week

Are you currently having problems with any of the following (please check all that apply):

General:	Fatigue	Weight Gain	Weight Loss	Amount over the past year?
Respiratory:	Cough	Shortness of breath with light activity
Breast:	Pain	Masses	Do you do a self-breast exam every month? yes no sometimes
Heart:	Palpitations	Chest Pain
GI:	Constipation	Diarrhea	Nausea	Vomiting	Rectal Bleeding
Menses:	Irregular	Heavy Flow	Painful Cycles	Missed Cycles	Bleeding Between Cycles
Menopause:	Hot Flashes	Moodiness	Night Sweats	Vaginal Dryness
Genital:	Itching	Burning	Discharge	Odor	Pain or bleeding with intercourse
Urinary:	Frequency	Urgency	Burning	Pain	Incontinence
Musculoskeletal:	Joint Pain	Muscle Pain	If yes, where:
Skin:	Acne	Mole	Bruising	Rash	If yes, where:
Neurological:	Headaches	Dizziness
Psychiatric::	PMS	Depression	Anxiety	Mood Swings	Insomnia

PREVENTATIVE EXAMS

Immunizations (indicate the date):
Tetanus   Hepatitis B   HPV(Gardasil)

If a screening test is ordered and returns to us as "abnormal", further testing may be done and will likely apply to your insurance deductible. This includes testing ordered at Annual or Well Woman exams.

We routinely check for Chlamydia with the pap smear if you are 25 or younger per the American College of Obstetricians and Gynecologists (ACOG) recommendations.

We also routinely check for Human Papilloma Virus (HPV) with the pap smear if you are 30 or older at least every 3 years per ACOG and American Cancer Society recommendations. The charge for this test may be applied to your insurance deductible.

By clicking "submit history" below, you acknowledge that appointments will be rescheduled for the following reasons:
     • If a patient is more than 15 minutes late for an appointment.
     • If a patient is unable pay for the office visit.
     • If children that need supervision from the staff (except for newborns) are brought to the appointment.
     • Rescheduling may be necessary in order for our staff to manage the schedule and for the courtesy of patients.