Please list any issues or concerns you would like to discuss at your visit:
Medical History: Current or previous conditions for which you have been diagnosed. Also any conditions for which you currently take medication to treat.
Surgical History: please list all previous surgery.
Family History: please list any medical conditions in you family. This includes parents, siblings, aunts and uncles and children. Please list the relative and the condition. i.e. Father - high blood pressure. Maternal Uncle - high cholesterol.
Current Medications: Please list all prescription and over the counter medications.
Please list all prescription and over the counter medications that you use.
When was your last pap smear? Which doctor performed it?
Please include name, and date of last visit.
When was your last mammogram? Where was it done?
When was your last colon cancer screening? Including colonoscopy, Cologuard or occult blood testing. Please include the doctor who performed or ordered the test.
File Upload: If you have any old records, you may upload them here.
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