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LPFP Med Update: Fem. 18+

Patient first name:

Last name:

Date of birth
(enter as MM/DD/YYYY or click to use the calendar):

Appointment date
(MM/DD/YYYY or click to use the calendar):

Provider:

1. Please list any new medical problems since your last physical examination here:

2. Please list any medical concerns you wish to address at this visit:

3. Have you seen a specialist or other healthcare provider since your last visit? YesNo

If yes, who did you see and what for? (Please sign a Release of Information form at the front desk)

Over the past two weeks, how often have you:

4. Felt little interest or pleasure in doing things? (choose one)
0: not at all1: several days2: more than half the days3: nearly every day

5. Felt down, depressed or hopeless? (choose one)
0: not at all1: several days2: more than half the days3: nearly every day

6. Are you sexually active?	YN
7. Are you currently sexually active with more than one partner?	YN If Yes, circle one: Male Female Both N/A
8. Would you like STD/STI screening today?	Y N
9. Have you had a hysterectomy?	YN
10. Have you gone through menopause?	YN
11. Do you have any abnormal vaginal bleeding?	YN
12. When was your last menstrual cycle?
13. What form of birth control do you use?
14. When was your last pap smear?
15. Have you ever had an abnormal pap smear?	YN If yes, when?
16. Do you do monthly breast self exams?	YN
17. When was your last mammogram?	Have you ever had an abnormal mammogram? Y N If yes, when and what were the results?
18. Have you had your stool tested for blood recently?	YN
19. Have you ever had any rectal bleeding?	YN
20. Have you ever had a colonoscopy?	YN If yes, when and what were the results?
21. Do you have any blood in your urine/urinary complaints?	YN
22. Do you take a baby aspirin daily?	YN
23. Have you ever had an exercise treadmill or other heart test performed?	YN If yes, when and what tests?
24. Please list any new medical problems your relatives have had since your last exam:	Father: Mother: Siblings: Children/Other:

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Timestamp

Audit

September 28, 2016 12:00 pm MDT

LPFP Med Update: Fem. 18+ Uploaded by Chris Madden - lpfp@myupdox.com IP 50.194.156.193