meridianprimaryhealthcare.com - Patient Health Form

Patient’s Name:

First NameLast Name
DOB:

MonthDayYear
Date
Date:

MonthDayYear
Date
Medications:
Please answer the following questions so that we may better serve your health needs.
Your Age:
Allergies:
If you have ever been pregnant, please indicate the number of the follow:
Pregnancies
Full-term live births
Premature live births
Abortions
Miscarriages
Living children
Age when you had your first menstrual period:
When was your last mammogram (x-ray of your breasts):
When was the FIRST day of your most recent period:
If menopausal, have you had a hysterectomy?

YesNo
Do you have any bothersome menopausal symptoms?
Are you on hormone replacement therapy?

YesNo
When was your last PAP smear?

Never1 yr ago2 yr> 3 yr
Were the results normal?

YesNo
Have you ever had an abnormal PAP test?

YesNo
If yes, did you have further evaluation (e.g. colpo, biopsy, rePAP, etc.):
How often do you usually get your period?

No periods
Every ________ days
Are your periods regular?

YesNo
How long do they last?
days
The blood flow is generally:

LightModerateHeavy
Do you have vaginal bleeding between periods?

YesNo
If menopausal, have you ever started bleeding again?

YesNo
Do you have any vaginal discharge that is different from your usual?

YesNo
Are you sexually active?

YesNo
Do you and your partner(s) use some form of birth control?

YesNo
Method:
Do you and your partner(s) use some form of STD protection?

YesNo
Method:
Have you ever had a sexual transmitted disease (STD)?

YesNo
Type:
Have you ever used fertility drugs?

YesNo
Has your mother ever taken a hormone called DES (diethylstilbestrol)?

YesNoUnknown
Do you smoke?

YesNo
How much per day?
How often do you perform self breast exams?

NeverOther
Has anyone ever abused or hurt you, either physically or verbally:

YesNo
Do you feel safe?:

YesNo

Do you have any family history of:

	No	Yes	Family member:
Breast Cancer:
Colon Cancer:
Uterine Cancer:
Ovarian Cancer:
Other Cancers:
Heart Disease:

On a scale of 1 to 10 (10 being the most severe) how would you rate your:
Premenstrual symptoms:

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Most severe
Pain during sex:

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Most severe
Pain during your usual period:

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Most severe
Please list any other concerns:
Should be Empty: