MUSKOGEE WOMEN'S CLINIC
DATE: ____________________
NAME _______________________________________					PLEASE ANSWER ALL QUESTIONS
AGE ________		MARITAL STATUS __________			ANY MEDICAL PROBLEMS WITH THE
REASON FOR TODAY'S VISIT?_________________					FOLLOWING:
____________________________________________							YES	NO
TOTAL PREGNANCIES _________					PELVIC PAIN
LIVE BIRTHS________ABORTIONS ___					VAGINAL DISCHARGE
LIVING CHILDREN ________					MEDICAL ILLNESSES
MISCARRIAGES ____ LAST PAP SMEAR ________					HYPERTENSION
DATE OF LAST PERIOD_____________________					DIABETES
LAST DEXA SCAN _________________					ASTHMA
LAST MAMMOGRAM_________________					HEART DISEASE
ANY PROBLEMS WITH PERIODS? _________					KIDNEY DISEASE
HORMONES? ________________________________					ARTHRITIS
ANY CONTRACEPTIVES? TUBAL? VASECTOMY?______________					GI PROBLEMS
_____________________________________________					DEPRESSION
PRIOR SURGERIES? _________________________					WEIGHT CHANGES
MEDICAL ILLNESSES? ________________________					WEAKNESS/FATIGUE
_____________________________________________					EYESIGHT
CURRENT MEDICATIONS: ______________________					FREQUENT COLDS
_____________________________________________					DIFFICULT BREATHING
DRUG ALLERGIES: ___________________________					CHRONIC COUGH
HAVE YOU BEEN IMMUNIZED FOR:					CHEST PAIN
			YES	NO	PALPITATIONS
DPT					ARM PAIN/NUMBNESS
TETANUS					FREQUENT NAUSEA
MEASLES					VOMITING
SOCIAL HISTORY:			YES	NO	DIARRHEA
					BLOATING
DO YOU SMOKE					CHANGE IN BOWELS
DO YOU USE ALCOHOL					BRUISING
DO YOU USE DRUGS					BLOOD IN STOOL
ANY PROBLEMS WITH FAMILY					URINARY FREQUENCY
ABUSE OR VIOLENCE					BURNING
ANY SEXUAL PROBLEMS					LEAKAGE
FAMILY HISTORY:			YES	NO	BLOOD IN URINE
PARENTS LIVING					HISTORY OF STONES
SIBLINGS LIVING					ANXIETY
DIABETES					SLEEP PROBLEMS
HEART DISEASE					MENTAL ILLNESS
BREAST CANCER					MUSCLE ACHES
COLON CANCER					JOINT PAINS
OVARIAN CANCER					SKIN RASHES
OTHER CANCER					BREAST MASS
OSTEOPOROSIS					BREAST TENDERNESS
					BREAST CHANGES
WEIGHT_________ HEIGHT______ BP ___________					BLEEDING EASILY
TEMP _________ PULSE __________					(HOW MANY PADS DAILY)