Desert West Obstetrics and Gynecology, Ltd.
Name ________________________________ Birthdate_________ Age _____ Date____________
Allergies to medications/food/environment Reaction Current Medications Instructions Reason Used
(Prescription, over the counter, herbal)
Prescribing Doctor
What do you do so you don't become pregnant? ____ Diaphragm
____ Other ___________________________________________________________________ First day of last period_________________________________ What age were you when you started your first period? ______________ Are your periods regular? ____________________ Is there bleeding between periods? ____________ How often do your cycles occur? ___________________________ For how many days do you bleed? __________________________ Flow is: ______ scant ______ mild ______ mod ______ severe ______ incapacitating Other symptoms with periods? ______________________________________________________________ _______________________________________________________________________________________ Date of last pap smear ___________________________________
How? ________________________________________________________________________
When was your last Mammogram (if any)? ___________________ Result ___________________________ Do you have concerns about your breasts? ____________________________________________________ When was your last Bone Density (if any)? ___________________ Result ___________________________
Past Medical / Surgical History(Include injuries and conditions requiring medication -i.e. -high blood pressure, seizures, diabetes, etc) Condition/Disease Treatment
Desert West Obstetrics and Gynecology, Ltd.
Name ________________________________ Birthdate_________ Age _____ Date____________ Have you had:
Total number of pregnancies Cesarean Premature Delivery Miscarriage Abortion Stillborn Pregnancy Details Number of Delivery Obstetrical/Neonatal Problems Delivery Doctor Family History
Please complete if any of your close relatives have had any of the following:
Family Members 1st Cause of Death Family Member (Circle)
Desert West Obstetrics and Gynecology, Ltd.
Name ________________________________ Birthdate_________ Age _____ Date____________ Social History Primary Language Spoken____________________________________
Do you smoke? No_____ Yes_____ If yes, type of tobacco?_______________ Number of years_____ Pks/day_____ Do you drink alcohol? No_____ Yes_____ If yes, type of alcohol____________________________________________ How often?__________________________ Amount______________________ Last drink________________________ Do you consume caffeine? No_____ Yes_____ If yes, what kind?_______________ Amount_____________________ Do you use recreational drugs? No_____ Yes_____ If yes, what kind?_______________________________________ Exercise frequency? Daily_____ Never_____ Occasional_____ 2-3times/wk_____ 4 or more times/wk_____ How many sexual partners do you have? None_____ One_____ 2-5_____ 5+_____ Have you been exposed to sexual or physical violence or abuse?
Are there animals in the home? No_____ Yes_____ If yes, what kind?_______________________________________ Is the patient the individual who cleans up after the animals?
If medically necessary, would you agree to a transfusion?
REVIEW OF SYSTEMS
If you are experiencing any of the symptoms listed, PLEASE CIRCLE THE ONES THAT APPLY, or write NONE. Constitutional (Health in General): Fatigue, fever, night sweats Ears, Nose, Mouth and Throat: Eye discharge, vision loss, ear drainage, hearing loss, nasal drainage Respiratory: Cough, wheezing, difficulty breathing or shortness of breath Cardiovascular: Chest pain, irregular heartbeat, palpitations Gastrointestinal: Abdominal pain, constipation, diarrhea, vomiting Genitourinary: Painful periods, pain with urination, blood in urine, excessive menstrual bleeding, vaginal discharge Neurologic/Psychiatric: Walking or balance difficulties, depression, anxiety, mood swings Dermatologic: Skin itching, rash Musculoskeletal: Bone weakness, joint weakness Hematology: Easy bleeding, easy bruising Immunology: Environmental allergies, food allergies
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Quit Tobacco Series WISCONSIN MEDICAID, BADGERCARE & SENIORCARE COVER TREATMENTS to QUIT TOBACCO Medicaid, BadgerCare and SeniorCare coverage for tobacco-dependence treatment applies to treatment provided by any Medicaid-certified Wisconsin physician, nurse practitioner or physician assistant. Did You Know? • The smoking rate among Wisconsin Medicaid adult recipi