Serenity GYN & Functional Medicine

DEMOGRAPHICS

Name:

DOB:

Age:

SSN:

Home #:

Mobile #:

Email Address:

Address:

Apt #:

City:

State:

Zip:

Driver's License #:

State:

Employer's Name:

Occupation:

Employer's Address:

Phone #:

City:

State:

Zip:

Person to notify in case of emergency:

Relationship:

Tel #:

Primary Physician's Name:

Phone #:

Pharmacy:

City/ Phone #:

FINANCIAL INFORMATION

Primary Insurance Co:

Tel #:

Insurance ID #:

Group #:

Insured's Name:

Insured's Date of Birth:

Relationship to Patient:

Secondary Insurance Co:

Tel #:

Insurance ID #:

Group #:

Insured's name:

Insured's Date of Birth:

Relationship to Patient:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature:

Date:

Patient History Questionnaire

Reason for this visit:

Marital Status:

Single Married Divorced Widowed

Medical History (Please Check All That Apply):

Heart Problems

Diabetic

High Blood Pressure

High Cholesterol

Fibromyalgia

Migraine Headaches

Depression/Anxiety

Other, please specify:

Current Medications:

Allergies to medicine or food?

Age at first period:

Are your menstrual periods regular?

Duration of bleeding:

Does bleeding or spotting occur between periods?

Does bleeding or spotting occur after intercourse?:

First day of last menstrual period?:

Is pain associated with periods? :

If so when?:

Do you have a sexual partner?

Yes No

If so, Male or Female?

Male

Female

Are there concerns about your sexual activity which you may want to discuss with your doctor?

Review of Systems:

General:

Changes in weight

Yes No

Progressive/Prolonged Fatigue

Yes No

Pulmonary:

Cough

Yes No

Shortness of Breath

Yes No

Wheeze

Yes No

Snoring

Yes No

Cardiac:

Do you ever wake up short of breath

Yes No

Leg/ Ankle swelling

Yes No

Do you sleep okay

Yes No

Palpitations / Heart flutters

Yes No

Abnormal sensation with exertion/ (in chest, arms, neck, back)

Yes No

Infectious Disease:

Fever

Yes No

Night Sweats

Yes No

Recent Infection

Yes No

Gynecologic/Urologic:

Incontinence

Yes No

Difficulty / Painful urination

Yes No

Blood in urine

Yes No

Psychiatric:

Suicidal thoughts

Yes No

Hallucinations

Yes No

Memory loss

Yes No

Feeling depressed/anxious

Yes No

Blood/Lymph:

Easy bruising

Yes No

Frequent nose bleeds

Yes No

Swollen glands

Yes No

Head and Neck:

Decrease in hearing

Yes No

Ringing in the ears

Yes No

New Headaches

Yes No

Sinus Problems

Yes No

Sore Throat

Yes No

Changes in voice

Yes No

Dry Mouth

Yes No

Eyes:

Blurred Vision

Yes No

Eye Pain

Yes No

Redness

Yes No

Watering

Yes No

Light sensitive

Yes No

Dry feeling

Yes no

Gastrointestinal:

Frequent Nausea / Vomiting

Yes No

Abdominal Pain

Yes No

Skin:

Changing moles

Yes No

New rash

Yes No

Tendency to form Keloid

Yes No

Neurological:

Dizziness

Yes No

Difficulty Walking

Yes No

Sensory Changes

Yes No

Musculoskeletal:

Weakness / Numbness

Yes No

Neck / Back Pain

Yes No

TMJ / Jaw Pain

Yes No

Surgical History

All Other Surgeries:

Any problems with anesthesia?

Pap Smear/Mammogram History

Date of last Pap Smear:

Was it normal?:

Have you had treatment for abnormal pap smears?

Date of last mammogram:

Was it normal?

Have you had any of the following? (check all that apply)

Venereal warts

Syphilis

Herpes – genital

Pelvic inflammatory disease

Endometriosis

Chlamydia

Gonorrhea

Vaginal infections

Pregnancy History (All pregnancies)

Year:

Full Term, Miscarriage or Abortion:

Duration Pregnancy:

Type of Delivery:

Complications:

Sex:

Birth Weight:

Present Health:

Add a new row for another pregnancy

Family & Social History

1. Do you smoke?

Yes No

Packs / day?

2. Do you use alcohol?

Yes No

How often?

3. Do you use recreational drugs?

Yes No

4. Do you exercise?

Yes No

If yes, how often?

5. Height:

Weight:

6. Do you have a family history of (who in your family):

Yes No

Diabetes:

Ovarian Cancer

Heart Disease

Breast Cancer

Colon Cancer

Other:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name / Signature:

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