•  PATIENT INTAKE HISTORY

  • Ko'olau Women's Healthcare, Inc.

    642 Ulukahiki St, #209 Kailua, HI 96734

    Phone: 808-230-8500 Fax: 808-230-8501

  • BIRTH DATE*
     - -
    2 digit month, 2 digit day, 4 digit year
  • TODAY'S DATE
     - -
    2 digit month, 2 digit day, 4 digit year
  • IS THIS A NEW PROBLEM?

  • If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse.

  • GYNECOLOGIC HISTORY

  • LAST NORMAL MENSTRUAL PERIOD (FIRST DAY):*
     - -
    2 digit month, 2 digit day, 4 digit year
  • HAVE YOU EVER HAD SEX?
  • SEXUAL PARTNERS ARE:
  • HAVE YOU EVER HAD AN ABNORMAL PAP TEST?
  • DO YOU DO BREAST SELF-EXAMINATIONS
  • HAVE YOU BEEN EXPOSED TO DIETHYLSTILBESTROL (DES)?

  • OBSTETRIC HISTORY

  • If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse.

  • (if never pregnant before please type 0 in first row)*
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  • Rows
  • COMPLICATIONS IN PREVIOUS PREGNANCIES
  • ANY HISTORY OF DEPRESSION BEFORE OR AFTER PREGNANCY?

  • CURRENT MEDICATIONS

    (including hormones, vitamins, herbs, nonprescription medication)
  • (if currently not on any medication please type NONE in first row)*
    Rows

  • FAMILY HISTORY

  • If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse.

  • Rows
  • FAMILY ILLNESSES
    Rows

  • SOCIAL HISTORY

  • If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse.

  • Rows

  • PERSONAL PROFILE

  • SEXUAL ORIENTATION

  • PERSONAL PAST HISTORY OF ILLNESSES

  • Rows
  • OPERATIONS/ HOSPITALIZATIONS
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  • INJURIES/ ILLNESSES
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  • IMMUNIZATIONS/ TEST
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  • REVIEW OF SYSTEMS

  • CONSTITUTIONAL
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  • EYES
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  • EAR, NOSE, AND THROAT
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  • RESPIRATORY
    Rows
  • GASTROINTESTINAL
    Rows
  • SKIN
    Rows
  • MUSCULOSKELETAL
    Rows
  • BREASTS
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  • GENITOURINARY
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  • NEUROLOGIC
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  • PSYCHIATRIC
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  • ENDOCRINE
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  • HEMATOLOGIC/LYMPHATIC
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  • MEDICATION ALLERGIES*
  • LATEX ALLERGY
  • Should be Empty: