Amber Tomse, Nurse Practitioner
FEMALE CONSULTATION MEDICAL HISTORY
NAME
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DATE
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Year
Date
ADDRESS
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PHONE #
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Email
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example@example.com
DOB
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Age
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Occupation
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Marital Status
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My Primary Health Concerns
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Allergies
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Primary Care Doctor
Phone #
Pharmacy
Phone #
Approximate date of Last complete physical exam
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Month
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Day
Year
Date
Upload any recent lab testing
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Women Last pap
Mammogram
Do you have a history of cancer? If so, what type?
If so what type
How long ago
Have you ever had a blood clot or been diagnosed with a blood clotting disorder
Have you ever been on hormone replacement therapy
Current Medications
Prescription and Non Prescription (Name/Dose/Reason for Taking)
Do you smoke?
How much?
How often?
When did you quit?
Do you use alcohol?
Type and how much per week?
Family History
List any serious problems (ex: cancer, diabetes, arthritis, heart disease, which relative?)
Females
Date of last menstrual period
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Month
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Day
Year
Date
Have you or a family member ever been diagnosed with PCOS
How many children do you have
Have you ever had a miscarriage
Did you have difficulty getting pregnant
Have you ever been diagnosed with ovarian cysts
Have you experienced difficulty with acne
Facial or body hair growth
Have you had a hysterectomy
Was it partial or complete
When
Describe current status of menstrual cycles
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Check Currenty Symptoms ONLY
Current Symptoms
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Rows
None
Mild
Moderate
Severe
Mental Fogginess
Forgetfulness
Depression
Minor anxiety
Mood changes
Difficulty falling asleep
Temperature swings
Day long fatigue
Decreased send of sexuality
Lessened self-image
Dry eyes, skin, vagina
Sagging breasts and loss of fullness
Weight gain
Joint/body aches and pain
Increase of breast size
Water retention
Impatient, snappy behavior
Pelvic cramps
Nausea
Flabbiness and muscular weakness
Loss of hair
Loss of coordination and balance
Decreased sex drive
Decreased hair (armpit, pubic, body)
Pain with sexual activity
Decreased muscle strength
Fibromyalgia
Lack of energy and stamina
Communication Preferences
Best time to reach you
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How do you prefer to be reached
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How did you hear about us
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Patient signature
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Physician signature
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