Falcon Health Center



New Patient -- Women’s Health Patient Name: _________________________________________ Date of Birth: ___________________Reason for visit: __________________________________________________________________________________________________________________________________________________________________________1st day of last menstrual period: ___________________________________________________________Are your menses regular (every 21-35days) or irregular? _______________________________________How often do they come? _________________________________________________________Is the flow heavy, normal or light? __________________________________________________Do you have cramps? YesNoDo you have bleeding between your menstrual periods? YesNoAre you using a birth control method or trying to get pregnant? _________________________________If Yes, what method of birth control do you use? ______________________________________Any breast concerns like nipple discharge, lumps or pain? YesNoDo you do breast checks on yourself at home? YesNoMedications:Please list all medications here including vitamins, supplements or herbs _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are you allergic to any medications, latex, or dyes? YesNoIf yes, please list them here ________________________________________________________Menstrual/Pregnancy History:How old were you when you had your 1st menstrual period? ____________________________________How many times have you been pregnant? __________________________________________________Medical History – please circle if you’ve had any of the following:AnemiaAsthmaAuto-immune Disorder like Lupus, Rheumatoid Arthritis, Multiple Sclerosis, Psoriasis or otherBreast ProblemsMedical History continued – please circle if you’ve had any of the following:CancerClotting disordersHeart Disease, heart murmur, blood pressure problems or high cholesterolDepression or mental health diagnosisDiabetesGallbladder problemsLiver conditions or HepatitisOvarian cysts, PCOS, pelvic masses or uterine problemsKidney or urinary tract problemsMigrainesThyroid problemsSurgeries (please provide age &/or year done if you recall) __________________________________________________________________________________________________________________________________________________________________________Family History – please circle any that apply to your blood relatives -- Mom, Dad, Sister/Brother, Aunt, Uncle, cousin, or Maternal & Paternal Grandparents. Alcoholism or Drug abuseAsthma, Allergies or EczemaAutoimmune Disorder like Lupus, Rheumatoid Arthritis, Multiple Sclerosis, Psoriasis or otherCancer (breast, ovarian, uterine, colon, skin, etc.)Heart disease, Heart Attack, High Blood Pressure, High Cholesterol or StrokeBlood clots in lung or legs, bleeding disorders, Anemia or Sickle CellDepression, mental health diagnosis or SuicideDiabetesGenetic disordersKidney disordersSeizuresThyroid problemsAny Women’s Health problems – Endometriosis, PCOS, Uterine FibroidsPersonal Habits:Do you use nicotine products like cigarettes, cigarillos or cigars? YesNoDo you vape? YesNoDo you drink alcohol? YesNoIf Yes, what do you drink (beer, wine, liquor, mixed drink, seltzer)? ________________________If Yes, how often do you drink? Rarely, monthly, bimonthly, weekly or ________days per week.If Yes, how many drinks will you have in a 24hour period (1 drink is equal to 12oz. beer, 5oz. wine or 1.5oz. shot)? _____________________________________________________________If Yes, how many times in the last year have you drank more than 4 drinks in a 24hour period? ______________________________________________________________________________Any drug use? YesNoIf Yes, what kind of drug(s)? _______________________________________________________Any caffeine intake? YesNoIf Yes, what type – coffee, tea, soda, energy drinks, other? _______________________________If Yes, how many cups daily? _______________________________________________________Any changes in sleep patterns? YesNoHow many hours do you usually sleep at night? _______________________________________Is your activity level moderate, sedentary or vigorous? ________________________________________What is your exercise frequency – 2-3x per week, 3-4x per week, daily, occasional or never? _____________________________________________________________________________________ ................
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