no no no no no no


Best Phone # to reach you: ... If the answer is no, please list your reason for this visit or any questions/problems you want to discuss with you healthcare provider.

Return GYN Patient Information

Have you been hospitalized or diagnosed with a medical

Personal Information

condition since your last visit?

Your Name: ___________________________________

If yes, please explain: ___________________________

Best Phone # to reach you: _______________________

_____________________________________________

Emergency Contact Person_______________________

_____________________________________________

Phone #________________________________ Are you here for your well woman exam?

□ yes □ no

□yes

□no

Has anyone in your immediate family developed a serious illness since your last visit?

□yes

□no

If the answer is no, please list your reason for this visit or

If yes, please explain: ___________________________

any questions/problems you want to discuss with you

_____________________________________________

healthcare

_____________________________________________

provider.______________________________________

Review of Systems

_____________________________________________

Fever / Chills

Yes

No

_____________________________________________

Headache / Sinusitis

Yes

No

Chest pain or pressure

Yes

No

Cough or shortness of breath

Yes

No

Depression / Anxiety

Yes

No

Nausea / Vomiting

Yes

No

List new or discontinued medications (including

Pain or frequency with urination

Yes

No

prescription and over the counter):_________________

Recurrent diarrhea or constipation

Yes

No

_____________________________________________

Vaginal rash or itching

Yes

No

_____________________________________________

Weight gain or loss

Yes

No

Visual changes

Yes

No

Hot or cold intolerance

Yes

No

Unusual hair growth or loss

Yes

No

Irregular or rapid heart beat

Yes

No

Stomach pain or discomfort

Yes

No

Blood in stool

Yes

No

Black or tarry stool

Yes

No

When was the first day of your last menstrual period? _____________________________________________ Since your last visit tell us what has changed: Medication List:

□yes

□no

□yes

Operations / Surgical Procedures

□no

List recent operations/ surgical procedures: __________ _____________________________________________ _____________________________________________ Have you been since your last visit?

□yes

□no

If yes, please list details below: Month/Year of birth/miscarriage:___________________ Sex of Baby: __________________________________

I have reviewed this history form with the patient.

Weight: ______________________________________ Type of Delivery: _______________________________ Have you found any breast lumps, discharge, or skin changes?

□yes

□no

Have you had a mammogram?

□yes

□no

If yes, where / when? ___________________________

_______________________________________ Provider Signature Date Vanderbilt One Hundred Oaks Ph# 615-343-5700 Fax# 615-343-6724 719 Thompson Lane Suite 27100 Nashville TN 37204 Vanderbilt Cool Springs Ph# 615-771-7580 Fax# 615-771-7025 2009 Mallory Lane Suite 230 Franklin T Revised 2/5/2010

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