Today's Date
MM
DD
YYYY
Name
*
First Name
Last Name
Email
*
Date of Birth
*
Needed for identification purposes--we have a lot of "same names"
MM
DD
YYYY
Age
Preferred Pronouns
Please indicate your main health concerns:
Medication Allergies
Please list any medications that you are allergic to or don't tolerate. Please describe the reaction (rash, swelling, nausea, etc.)
Current Medications, Vitamins, and Supplements
Include all prescriptions, over-the-counter medications, herbal, or dietary supplements, as well as the dose and how often it is taken. If you prefer to bring a list or your pill bottles to the visit, that is fine. If you bring a list or the bottles, you may skip this section.
General
Skin
If "Other," please describe:
Head, Eyes, Ears, Nose, Throat
Nodes and Glands
Breasts
Lungs
Cardiovascular
Gastrointestinal
Genito-Urinary
Musculoskeletal
Neurological/Psychiatric
Do you have any sexual concerns?
Are you currently sexually active?
Number of sex partners in the past 3 months?
0
1
2
3
4
5
6
7
8
9
10 or more
Who do you have sex with?
Decreased sex drive/Low libido?
Discharge from penis?
Difficulty getting an erection or maintaining an erection?
Difficulty starting to urinate?
Decreased urinary stream?
Do you have any sexual concerns?
Are you currently sexually active?
Pain with intercourse?
Number of sex partners in the past 3 months?
0
1
2
3
4
5
6
7
8
9
10 or more
Who do you have sex with?
Loss of sex drive/Other sexual difficulties?
If "Other," please describe:
Do you use any type of Birth Control?
If "yes," what type:
Date last normal menstrual cycle began:
MM
DD
YYYY
Are your periods regular?
Do you get painful menstrual cramps?
How long does your period last?
Do you get spotting between periods?
Have you tried to get pregnant unsuccessfully?
Have you sought care for infertility?
Number of pregnancies
0
1
2
3
4
5
6
7
8
9
Number of live births
0
1
2
3
4
5
6
7
8
9
Number of miscarriages
0
1
2
3
4
5
6
7
8
9
Number of elective terminations
0
1
2
3
4
5
6
7
8
9
Have you gone through menopause?
Age at menopause?
Who is your GYN?
Last Pap smear/gyn exam?
(if exact date unknown, select the 1st of the month)
MM
DD
YYYY
Last Bone density test (dexa: for postmenopausal)
(if exact date unknown, select the 1st of the month)
MM
DD
YYYY
Last Mammogram
(if exact date unknown, select the 1st of the month)
MM
DD
YYYY
Relationship status:
How do you identify your gender?
If "Other," please describe:
What is your sexual orientation?
1. How often do you have a drink containing alcohol?
2. How many standard drinks containing alcohol do you have on a typical day?
3. How often do you have six or more drinks on one occasion?
Do you drink beverages containing caffeine?
If so, what do you drink and how often?
Do you smoke?
If "yes," how many cigarettes a day?
If "no," how long ago did you quit?
Do you vape?
Do you use recreational drugs?
If "yes," please list:
Do you use any medication prescribed FOR another person?
What do you do for exercise?
Do you have guns in the home?
If "yes," are they stored safely?
What are your hobbies/interests?
Do you have Advance Directives?
Tetanus (every 10 years)
MM
DD
YYYY
Tetanus/Pertussis (TdaP)
MM
DD
YYYY
Pneumonia: Pneumovax
MM
DD
YYYY
Prevnar 13
MM
DD
YYYY
Prevnar 20
MM
DD
YYYY
Shingles: Shingrix #1
MM
DD
YYYY
Shingrix #2
MM
DD
YYYY
(Please indicate Pfizer or Moderna)
#1
MM
DD
YYYY
#2
MM
DD
YYYY
#3
MM
DD
YYYY
#4
MM
DD
YYYY
#5
MM
DD
YYYY
#6
MM
DD
YYYY
RSV: Arexvy
MM
DD
YYYY
Abrysvo
MM
DD
YYYY
Last Colonoscopy (over age 45, sooner if family history):
MM
DD
YYYY
Where else have you received care in the past year?
Select all which apply. Note details below.
If "Others," please list
Please list any surgeries you have had (since your last physical here):
Include date and type of surgery.
Diabetes
Cancer
High blood pressure
High cholesterol
Heart attack
Stroke
Add any additional detail below.
1. Little interest or pleasure in doing things
0
1
2
3
2. Feeling down, depressed, or hopeless
0
1
2
3
3. Feeling nervous, anxious or on edge
0
1
2
3
4. Not being able to stop or control worrying
0
1
2
3
