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?
Do you have any bothersome menopausal symptoms?
Are you on hormone replacement therapy?
When was your last PAP smear?
Were the results normal?
Have you ever had an abnormal PAP test?
If yes, did you have further evaluation (e.g. colpo, biopsy, rePAP, etc.):
How often do you usually get your period?
Every ________ days
Are your periods regular?
How long do they last?
days
The blood flow is generally:
Do you have vaginal bleeding between periods?
If menopausal, have you ever started bleeding again?
Do you have any vaginal discharge that is different from your usual?
Are you sexually active?
Do you and your partner(s) use some form of birth control?
Method:
Do you and your partner(s) use some form of STD protection?
Method:
Have you ever had a sexual transmitted disease (STD)?
Type:
Have you ever used fertility drugs?
Has your mother ever taken a hormone called DES (diethylstilbestrol)?
Do you smoke?
How much per day?
How often do you perform self breast exams?

Other
Has anyone ever abused or hurt you, either physically or verbally:
Do you feel safe?:

Do you have any family history of:

Rows	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: