Pink Link Medical- FEMALE Patient History Form

All of your information will remain confidential between you and Pink Link Medical.

Please take your time filling out this questionnaire completely and honestly.

This questionnaire is 7 pages long and covers a lot of information, so be prepared to spend a minimum of 30-45 minutes completing.
FEMALE PATIENT HISTORY
PATIENT DETAILS
Full Name

First NameLast Name
Birth Date:

MonthDayYear
Age:
CONTACT INFO
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mobile Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
E-mail
Referred by:
DEMOGRAPHICS
Hispanic or LatinoNot Hispanic or LatinoDecline to Answer
American Indian or Alaska Native AsianAsian or Subcontinent of AsiaBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteDecline to Answer
EMERGENCY CONTACT
Name
Relation
Phone Number
PHARMACY
INSURANCE

TO BE USED FOR LABS.
Name--Phone Number--Address--ZIP CODE
Insurer's Name
Insurer's SS#
Insurer's DOB
Relation to Insurer
Insurance Name:
Employer Name:
Plan Name:
Group #
Member ID # :
Effective Date:
Copay Amount:
Claims Address and Phone #:
REFERRED BY:
MAIN REASON FOR VISIT
FAMILY MEDICAL HISTORY
Family History of Cancer, Blood Clots, Seizures
Age, Significant Health Problems
Father
Mother
Siblings
MEDICAL HISTORY
Alcohol AbuseAnemiaAnxietyArthritisAsthmaAutoimmune ProblemsBlood ClotsCancer (type:______________)DepressionDiabetesDifficult PregnanciesDizzinessEating DisorderGoutHeartburn/IndigestionHeart DiseaseHepatitisHigh Blood PressureHigh CholesterolInsomniaKidney ConditionsMenopause SymptomsMigrainesObesity/OverweightPCOSPituitary DisorderSleep ApneaStrokeThyroid DisorderTumorsUlcersSeizures or Seizure DisorderDrug AbuseOther
DehydrationDiarrheaFever/ChillsNausea/VomitingOther
Additional information related to your Medical History you would like us to know:
PREVENTATIVE CARE
Last Date Done & Results (-/+)
Bone Density (Date & Results)
Colonoscopy (Date & Results)
Complete Physical (Date & Results)
Pap Smear (Date & Results)
Mammogram (Date & Results)
PERSONAL HISTORY
MarriedSingleIn a RelationshipEngagedDivorcedWidowed
Children/Ages:
Pets:
Occupation:
YesNo
PrimaryObgynChiropractorNaturopathOther
12345678910
What do you consider your main source of Stress?
MAJOR EVENTS
Hospitalizations, surgeries, births, cosmetic and/or weight loss procedures
List Reasons-Diagnosis-Date
List Reasons-Diagnosis-Date
List Reasons-Diagnosis-Date
MEDICATION ALLERGIES
No Known Allergies
List Name of Medications and Reactions
FOOD ALLERGIES
List Name of Food Allergy and Reactions
ENVIRONMENTAL ALLERGIES
List Name of Environmental Allergy and Reactions
PRESCRIPTION MEDICATIONS
List All Medication Name, Dose & Frequency, Approximate State Date & Reason for Use
SUPPLEMENTS AND OVER-THE-COUNTER
List Name of Supplement, Dose & Frequency, Approximate start Date & Reason for Use
SLEEP
Describe a typical nights sleep:
How many Hours of sleep? Do you take anything to help you sleep? Do you fall asleep easily? Do you wake up often? Do you dream? Do you snore loudly? Do you feel rested in the mornings? Do you feel tired in the afternoons?
FITNESS LIFESTYLE

Health Habits- Activity Levels

Rows	Pick One
Sedentary
Mild Exercise
Occasional Vigorous Exercise (less than 4x/week at least 30 min
Regular Vigorous exercise (4x/week for at least 30)
Recreational Athlete
Professional Athlete

Describe your excersise routine:
How long have you been following this routine?
HABITS THAT AFFECT YOUR HEALTH
YesNo
If yes, what kind?
If yes, how many per day/week/month
YesNo
If yes, how many packs per day/week/month
If past use, when did you quit?
YesNo
If yes, what kind?
If yes, how many per day/week/month

Rows	None	Mild	Moderate	Severe
Anxiety
Brain "Fog" Memory/Concentration Loss
Carpal Tunnel
Chronic Back Pain
Cold Intolerance
Constipation
Decreased Libido
Depression
Difficulty Awaking Fully
Discomfort during Sex
Dry/Brittle Hair
Dry/Brittle Nails
Excess Abdominal Fat
Fatigue
Fragile/Thinning Skin
Frequent colds/flu
Hair Loss
Heat Intolerance
Hives/Eczema
Insomnia
Low immune system
Panic Attacks
Poor Motivation
Poor Muscle Mass
Prolonged Soreness after Exercise
Sexual Dysfunction
Stiff Joints
Thinning Hair
Unexplained Numbness, or Tingling
Unexplained Weight Gain
Unexplained Weight Loss
Vertigo/Dizziness
Weight Gain in spite of good nutrition/exercise

Rows	Yes	No
ADHD
Bipolar
Celiac disease
Chronic fatigue syndrome
Elevated liver Enzymes
Gallstones
Hypoglycemia
Insulin Resistance
Multiple sclerosis
Osteopenia
Osteoporosis
Personality Disorder
Psoriasis
Reynaud’s syndrome
Rheumatoid arthritis
Systemic lupus erythematosus
Type 1 Diabetes
Type 2 Diabetes
Vitiligo

Rows	Yes	No
Any uncontrolled Leakage?
Leakage of urine when coughing, sneezing, exercising or jumping?
Strong urge to urinate but can't make it to the restroom on time?
Burning with urination?
Urinary urgency?
Diagnosed with Hematuria (constant blood in urine)?
Diagnosed with Interstitial Cystitis and urgency frequency?
Have you experienced bladder, uterine or rectal prolapse?

Rows	less than 10%	10%-25%	25%-50%	50%-75%	75% or more
weekly vegetable intake

Rows	less than 10%	10%-25%	25%-50%	50%-75%	75% or more
weekly fruit intake

FEMALE PATIENT HISTORY

PATIENT DETAILS

CONTACT INFO

DEMOGRAPHICS

EMERGENCY CONTACT

PHARMACY

INSURANCE

REFERRED BY:

MAIN REASON FOR VISIT

FAMILY MEDICAL HISTORY

MEDICAL HISTORY

PREVENTATIVE CARE

PERSONAL HISTORY

MAJOR EVENTS

MEDICATION ALLERGIES

FOOD ALLERGIES

ENVIRONMENTAL ALLERGIES

PRESCRIPTION MEDICATIONS

SUPPLEMENTS AND OVER-THE-COUNTER

SLEEP

FITNESS LIFESTYLE

HABITS THAT AFFECT YOUR HEALTH

GENERAL HORMONE EVALUATION

FEMALE HORMONE EVALUATION

URINARY SYMPTOMS

WEIGHT INFO

NUTRITION EVALUATION

ADDITIONAL INFORMATION

Rows	Never	Seldom	Frequently
Stomach Spasms/Cramps
Strong emotions cause stomach pain/discomfort
Burning sensation
Certain Foods (Spicy, acidic, coffee, etc.) cause burning/aching anywhere in your GI system
Nausea with Meals

Rows	Yes/No
I eat when I’m stressed or sad.
I binge eat.
I overeat.
I use high fructose corn syrup.
I use agave nectar.
I drink sweet tea.
I drink sugary drinks.
I plan my meals.
I shop for foods.
I cook my meals.
I use a grocery list for shopping.

Rows	Never	Seldom	Frequently
Bad Taste in Mouth
Burping and Belching
Bloating or Fullness in Upper Digestive tract
Lack of Appetite
Food "Repeats"

Rows	Never	Seldom	Frequently
Experienced chronic Intestinal or lower bowel discomfort (unrelated to meals) for more than 6 months?
1-4 hours after your meal, have lower abdominal bloating, cramps, gas
1-4 hours after your meal, have lack of appetite
1-4 hours after your meal, have strong stool odor
1-4 hours after your meal, have gas and bloating with fatty foods
1-4 hours after your meal, have undigested food particles in stool
1-4 hours after your meal, have fatty stool or mucus in stool
1-4 hours after your meal, have loose stool or diarrhea