New Patient Information

New Patient Information - Female

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Susan Kady Wilson, MD

Larry Wilson, MD

CharlestonHealthSpan.com
Ph 843.375.6588
Fax 843.353.1610

125 River Landing Drive, Suite #101, Daniel Island, SC 29492

407 Church Street, Unit C, Georgetown, SC 29440

923 Medical Circle, Myrtle Beach, SC 29572
Date*

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Date
Full Name*

First NameLast Name
Date of Birth*

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Date
Contact Number*
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Address*

Street Address

Street Address Line 2

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Email*
example@example.com
Best contact method for appointment reminders and lab results:

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Do you have Medicare or Medicaid?*

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Reason for Medicare:

AgeDisabilityESRD
Can we obtain prescription history from your pharmacy?

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Emergency Contact Name:*

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Emergency Contact Phone Number:*
Please enter a valid phone number.
How did you hear about Charleston HealthSpan Institute / Who referred you?
What is the primary reason for your visit today?*
Present Symptoms of concern:*
Have you previously been prescribed Hormone replacement Therapy?*
Do you have any allergies?*

YesNo
Allergies:
List of all current medications and supplements: (Please include dosage)*
Do you have any medical problems?*
Surgery History:*
Family Medical History: *
Do you smoke?*

YesNo
If yes, please specify how many packs per day and for how many years:
Do you drink alcohol regularly?*

YesNo
If yes, how many drinks per week?
Do you exercise regularly?*

YesNo
If yes, how many hours per week?
Female Health Questionnaire
If needed, what birth control method is utilized?
Has your husband/significant other had a vasectomy?
When was your last Mammogram?*
When did your last Menstrual Cycle begin?*
How many times have you been pregnant?*
How many Children?*
Ages?
Have you had a Hysterectomy?*
Date of Hysterectomy:

MonthDayYear
Date
What is your Height? x'x* Weight? xxx* Ibs
Place a Check ✓ mark if you have experienced:

DepressionUnexplained weight GainInsomniaAnxietyRapid weight gainHeadachesFeelings of AngerCraving for sweetsMigraine headachesIrritabilityIntolerance to exerciseNight SweatsConfusionAcnePuffiness and bloatingDry eyeLow LibidoBreast tendernessWeepinessInfertilityHot FlashesMood swingsPainful IntercourseLow blood pressureFoggy thinkingThyroid ProblemsOvarian cystsNervousnessVaginal DrynessIncrease of Facial HairFatigueHeavy bleedingIncrease of Body HairForgetfulnessTiredPalpitationsMemory LossLethargicJoint PainUrinary IncontinenceLeaky Bladder
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Consent for Bio-Identical Hormone Replacement Therapy:*

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New Patient Information - Female

Female Health Questionnaire