FemiWave® Intake
Patient Name:
Date:
-
Month
-
Day
Year
Date
Age:
DOB:
-
Month
-
Day
Year
Date
Height:
Weight:
Allergies:
Social History
Alcohol Use:
Yes
No
If yes, how many drinks per week?
Recreational drugs
Yes
No
If yes, which ones?
Smoker
Yes
No
If yes how many packs per day?
Medications
List all medications or drugs you are now taking or take often including prescription medications, over-the-counter medications, herbal medications, vitamins, minerals, or supplements (please include hormone replacement therapy).
Medical/Surgery History
Check the conditions you currently have or had in the past:
Abnormal Pap
Bleeding Disorder
Cancer: Cervical normal
Chest radiation
Diabetes
Endometriosis
Gallbladder removed
Heart Surgery
High Cholesterol
Kidney Failure
Migraine
Psychiatric Disorder
Surgery for Weight Loss
Uterus, tubes, ovaries removed
Anemia
Blood Transfusion
Cancer: Ovarian
Clotting Disorder
Drugs/Alcohol Abuse
Fibroid uterus
Genital Warts
Heart Valve Disease
Hysterectomy
Liver Biopsy
Osteoporosis
Pulmonary
Embolism
Thyroid Disease
UTI, recurrent
Asthma
Breast Cancer
Cancer: Uterine
D&C
DVT
Fracture
Heart Attack
Hernia Repair
Infertility
Liver Disease
PCOS
Seizure/Epilepsy
Tubal Ligation
Vaginitis
Atypical hyperplasia
Breast Surgery
Cesarean Section
Depression
Eating Disorder
Gallbladder Disease
Heart Failure
High Blood Pressure
IBS
Lupus
PID
Stroke
Tuberculosis
Other
Diagnostic Test History
Do you leak urine when you cough, sneeze, run or lift heavy objects?
Yes
No
When?
Was it normal?
Pregnancy History
Have you ever been pregnant?
Yes
No
Number of births:
Miscarriages:
Abortions:
Ectopic/Tubal:
C-Sections:
Breastfeeding:
Yes
No
List any problems with a pregnancy , birth or abortion:
Current or past birth control:
Yes
No
If yes, any side effects?
Sexual History
Married
Single
Dating
Sexually Active:
Yes
No
Inactive
Have you been exposed to a Sexually Transmitted Infection (STI) recently?
Yes
No
If yes, please note below:
Bacterial Vaginosis
Chlamydia
Genital Herpes
Gonorrhea
HIV/AIDS
Syphilis
Trichomonas
Yeast Infections
Other:
Lifestyle/Challenges/Support
Any recent major life changes?
Yes
No
If yes, please explain:
Submit
Should be Empty: