INITIAL INTAKE FORM
Please complete ALL sections below!
Orange Coast Women's Medical Group, Inc. (949)829-5500
*Patient Name: *Birth Date: (MM/DD/YYYY) Account #:
*Email:  
Important: In order to provide the highest quality of health care possible, it is important that we have the following information. Please answer all of the doctor's questions as accurately as possible. If you do not understand the question please ask for assistance. Thank you.
*Please describe the reason(s) for this visit:
*Drug allergies:
*List any medications you are taking, including non-prescription drugs, vitamins, and herbals:
Female Genitourinary (Please Complete):
Date of last pap smear?
*Any abnormal pap smears? No Yes
Date of last mammogram?
Result of mammogram normal? No Yes
Date of last bone density test?
Result on bone density normal? No Yes
*Any problem w/leaking urine? No Yes
*Are you sexually active? No Yes
Do you have pain w/intercourse? No Yes
*Bleeding between periods? No Yes
*Vaginal discharge/itching? No Yes
Bleeding after intercourse? No Yes

Menstrual History:

*Age period began: Average # of days: Do you use hormones? No Yes
*Date of last period: Method of contraception: If so, type:
*Frequency of periods: Satisfied with this method? No Yes Any vaginal bleeding? No Yes

Past Medical History:
Have you ever had the following:
*Diabetes No Yes *Thyroid dysfunction No Yes *Infertility No Yes
*Hypertension No Yes *Major accidents No Yes *Mitral Valve Prolapse No Yes
*Heart Dz/High Cho No Yes *Stomach/Intestinal No Yes *Cancer No Yes
*Obesity No Yes *Tuberculosis No Yes *Anemia No Yes
*Kidney dysfunction No Yes *Asthma No Yes *Glaucoma No Yes
*Mental Disorder No Yes *Herpes No Yes *AIDS or HIV+ No Yes
*Hepatitis/Liver dz No Yes *Anesthetic complication No Yes  

Past Surgical History:
Have you ever had the following: *D & C No Yes *Cryosurgery No Yes
*Hysterectomy No Yes *Breast biopsy No Yes *Colposcopy No Yes
*Surgery on tubes/ovaries No Yes *Breast cyst aspiration No Yes *LEEP/Cone biopsy No Yes
*Cesarean delivery No Yes *Mastectomy No Yes *Urologic No Yes
Please list any other previous surgeries or any other major illnesses and dates:

Obstetrical History (Please Complete):
Year Wt. Sex #wks pregnant Duration of Labor C-section? Complications?

Social History (Please Complete):
Occupation:
*Do you exercise? No Yes
Type:
How often?
*Smoking (type & amount per day) No Yes
If former smoker, date quit:
*Marital Status: S M W D
*Have you ever been sexually abused? No Yes
*Have you ever felt physically or emotionally threatened? No Yes
*Do you get calcium in your diet? No Yes
Supplements:
*Alcohol (type and amount per week):
*Do you use marijuana, cocaine or other drugs? No Yes
If yes, what type?

*Family Medical History
Medical Problem Family Members Affected Choices: Mother, Father, Sibling, Maternal Grandmother, Maternal Grandfather
High Cholesterol No Yes    Who:
Heart Disease No Yes    Who:
High Blood Pressure No Yes    Who:
Breast cancer No Yes    Who:
Melanoma No Yes    Who:
Diabetes No Yes    Who:
Ovarian cancer No Yes    Who:
Stroke No Yes    Who:
Blood disorder No Yes    Who:
Depression No Yes    Who:
Colon cancer No Yes    Who:
Osteoporosis No Yes    Who:

Review of Systems (Please Complete):
Do you have now or have you had within the past year:
Const *Weight Gain/Loss No Yes CV *History of heart attack No Yes Psych *Depression No Yes
GI *Bloody stools No Yes   *History of blood clots in legs or lungs No Yes Skin *Painful breasts No Yes
  *Abdominal pain No Yes Neuro *Seizures No Yes   *Breast lumps No Yes
  Date of last colonoscopy   *History of stroke No Yes   *Nipple discharge No Yes
Endo *Night sweats No Yes   *History of migraines No Yes   *Other
  *Hot flashes No Yes Resp *History of asthma No Yes
Heme *Bruising easily No Yes

I VERIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
X
Signature of patient or parent if minor *Date(MM/DD/YYYY)
You will be asked to sign your sheet upon check-in at our offices.


    
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