AGELESS HEALTH INNOVATIONS
Patient Health History: WOMEN
Date
-
Month
-
Day
Year
Date
Chart # (administrative use only)
Patient Name
First Name
Middle Name/Initial
Last Name
Date of last Physical Exam (month + year)
Primary Care Doctor (PCP):
Personal Health History
Check all that apply
Cardiovascular disease
Chest pain
Heart failure
Murmur
Vascular disease
Blood clots
Fainting
Lower extremity edema
None
Other
Respiratory disease
Shortness of breath
Asthma
Bronchitis
Pneumonia
Allergies
Hay fever
None
Other
Gastrointestinal disease:
Lactose intolerance
Gallbladder
Gall stones
Diarrhea
Constipation
None
Other
Genitourinary disease:
Overactive bladder
Frequent urination
Painful urination
Difficult urination
Diabetes
High Blood Pressure
Cancer
Depression
High Cholesterol
Sleep Apnea
None
Other
Surgeries
Year
Surgery
City+State
List your prescribed medications and over-the-counter drugs, such as vitamins and inhalers here OR, use the box below to upload a picture or document listing your medications.
Name the Medicine
Strength
Frequency Taken
Upload a picture or document listing your medications
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Allergies To Medications
Name The Drug
Reaction You Had
.
.
.
Health Habits And Personal Safety
Exercise
None at this time
Occasionally
Regularly
Mild
Vigorous
Other
Alcohol
Yes
No
Tobacco
Yes
No
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Ageless Health Innovations
Patient Health History: WOMEN
Urogenital Health: Please answer "Yes" or "No" to each question
Yes
No
Any blood in your urine?
Has the force of your urination decreased?
Have you had any kidney, bladder, infections within the last 12 months?
Do you have any problems emptying your bladder completely?
Any difficulty achieving orgasm?
Date of last colonoscopy-- or, insurance approved at-home colon cancer screening i.e.: Cologuard (month + year -- or, haven't had one)
REVIEW + SIGNATURE
I have received or reviewed the Privacy Practices Notice for Ageless Health Innovations (three (3) pages, link for review below). I understand the situations in which this practice may need to utilize or release my medical records. I understand that this office will properly maintain my records and will use all due means to protect my privacy as outlined in this Privacy Practice Notice.
Your signature constitutes your understanding of the above information.
Date
/
Month
/
Day
Year
Date
PRIVACY PRACTICES REVIEWABLE HERE
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