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    Women's Health Associates of Richardson

    • Health Questionnaire

      Please provide as much information as possible here. 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? May we leave messages at this number? yes no

      Email Address:

      Date of Birth: Age: SSN#: Sex

      Who are you seeing today?
      Charles Downey, MD Dr. Carol Norton, MD Jan Risden, MD Cori Poovey, NP Daphne McDonald, NP

      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:

      HEALTH QUESTIONNAIRE

      Last Period:

      Reason for Visit:

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

        Skin: Acne Mole Bruising RashIf yes, where:
        Vision: Unaided Glasses Contacts Lasik
        Hearing: Unaided Aided Hearing Deficit
        Menopause: Hot Flashes Moodiness Night Sweats Vaginal Dryness
        Breast: Pain MassesDo you do a self-breast exam every month? yes no sometimes
        Heart: Palpitations Chest Pain
        Lungs: Cough Shortness of breath with light activity
        GI: Constipation Diarrhea Nausea Vomiting Rectal Bleeding
        Urinary: Frequency Urgency Burning Pain Incontinence
        Vaginal: Itching Burning Discharge Odor
        Weight: Stable Increased DecreasedAmount over the past year?
        Psychiatric:: PMS Depression Anxiety Mood Swings Insomnia
        Neurological: Headaches Dizziness
        Musculoskeletal: Joint Pain Muscle Pain If yes, where:

      MENSTRUAL HISTORY

      Menstrual History: Hysterectomy Menopause

      If still having cycles: How many days apart? How many days do they last?

      Current Menstrual Problems: Heavy Bleeding Pain Clots Bleeding between periods

      Date of last pap smear: Normal Abnormal

      Date of last mammogram (if applicable): Where?

      Sexually Active: yes Not Currently never   Any Concerns? Pain Bleeding Dryness

      Sexual partners are: Male Female both

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

      Primary Care Provider or Family Physician:
      May we exchange medical information with your PCP? yes no

      OBSTETRICAL HISTORY

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

      Type of Delivery: C-Section How many Vaginal How many

      Largest baby:

      Have you ever had any of the following (if yes, please specify the number of times):
      Miscarriage , Ectopic Pregnancy , Termination

      GYNECOLOGICAL HISTORY

      Please indicate if you have had any of the following procedures and the year performed.

        Hysterectomy: Abdominal Vaginal Ovaries Removed   Year
        Laparoscopy for: Ovary Pelvic Pain Endometriosis Other  Year
        Tubal Ligation: Laparoscopic Hysteroscopic Post Partum  Year
        Breast: Implants Reduction Biospy  Year
        Uterus/Cervic: LEEP Cervical Cone Cryotherapy (Freezing) D&C  Year

      Other gynecological procedures (please list):

      Have you ever had an abnormal Pap Smear? yes no   Year of abnormal Pap?

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

      How old were you when you had your first period?

      If menopausal, at what age did you have your last period?

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

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

      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:)

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

      PAST HISTORY

      Past Medical History: (Hypertension, Diabetes, Asthma, Injuries, Blood transfusion, etc.)

          Diagnosis  Date  Treating MD
           
           
           
           

      Non-Gynecological Surgeries: (Colonoscopy, Gallbladder, Appendix, etc)

          Surgery  Date  Diagnosis
           
           
           
           

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

      Drug Allergies: (Sulfa, Penicillin, Myacins, etc)

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

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

      Current Medications

          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:

      SOCIAL HISTORY

      Occupation:

      Education: High School College Graduate School   Other:

      Marital Status: Single Engaged Married Widowed Separated Divorced Significant Other

      Live with: Alone Roommate Family Spouse Fianc� SignificantOther

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

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

      Smoke: 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: day week month year

      Caffeine: no yes   servings per day

      Drug Use: no yes   type and frequency

      Do you have a living will (advanced directive): no yes

      FAMILY HISTORY

      Mother: alive deceased (from )

      Father: alive deceased (from )

        Condition  Maternal/Paternal  Family Member
        Breast Cancer  M P  
        Uterine Cancer  M P  
        Ovarian Cancer  M P  
        Colon Cancer  M P  
        Osteoporosis  M P  
        Blood Clot / DVT  M P  
        Heart Attack  M P  
        High Blood Pressure  M P 
        High Cholesterol  M P  
        Stroke  M P 
        Diabetes  M P  
        Thyroid Disorder  M P  
        Depression  M P  
        Congenital Birh Defects  M P 
        Other  M P  

        Preventative Date  Ordering Physician
        Blood Work   
        Bone Density   

      If a screening test is ordered and returns to us as "abnormal", further testing may be done and will likely be applied 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 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.

      If you do not want HPV testing, check here:

      Are you interested in screening for sexually transmitted diseases? (You will want to check insurance coverage before blood is drawn) Yes No

      Do you have a preference on where you have lab work drawn? Yes No Determine by my insurance
      If yes, which one? LabCorp Quest

      The following information must be provided at your appointment: insurance cards, Driver’s License or picture ID, and a major credit card. This information is necessary in order for our office to process your insurance claims more efficiently.

      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.


       

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    • Women's Health Associates of Richardson

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