Please complete all pages. Your answers on this form will help us understand your medical concerns and conditions better. If you are uncomfortable with any questions, you do not have to answer it. Best estimates are acceptable.
Your Name (required)
Your Email (required)
Papsmear (required) YesNo
ECG (required) YesNo
PRESENT HEALTH CONCERNS
MEDICATIONS
Please list any prescription and non-prescription medicines, vitamins, home remedies and birth control pills
ALLERGIES OR REACTIONS TO MEDICINES, FOODS AND/OR OTHER AGENTS
PERSONAL MEDICAL HISTORY
Please indicate whether you have had any of the following medical problems and an approximate date of illnesses or diagnosis
SURGICAL HISTORY
WOMEN’S GYNECOLOGIC HISTORY
For women to answer only
No. of Pregnancies
No. of Deliveries
No. of Abortions
No. of Miscarriages
1st day of most recent period
Age at 1st period
Frequency of periods
Length of each period (days)
State any concerns you have about your periods
State any concerns you have about menopause
FAMILY HISTORY
Please indicate if any of your family members have had any of the conditions stated and state your relationship with this member
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