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LIFEPOINT INSTITUTE FOR WOMEN
Denard M. Fobbs, M.D.

S P E C I A L G Y N E C O L O G Y

PATIENT HISTORY

Today's date

Name*

Address

Telephone

Chief Complaint*

Date of Birth

Marital Status

SYMPTOMS*

PELVIC PAINPAINFUL INTERCOURSE/DISCOMFORTOVARIAN CYSTSVAGINAL DRYNESS/INFECTIONSLOWER BACK PAINLACK OF URINE CONTROLJOINT/MUSCLE PAINABDOMINAL PAINIRRITABLE - ANGRYWANT TO BE ALONEPOOR MEMORY/FORGETFULNESSRACING THOUGHTSANXIETYFEELING OVERWHELMEDFEELING OUT OF CONTROLFEELING OF CONFUSIONDIZZINESS/FAINTINGDIFFICULT TO CONCENTRATECRAVINGS FOR SWEETS/SALTBINGE EATINGOVER EATINGMIGRAINESDRY SKIN OR NAILSACNE/OILY SKINLACK OF ENERGY/TIREDEXCESS/ ABNORMAL HAIR GROWTHHAIR LOSSFEEL TEARFULDIFFICULTY HAVING ORGASMLACK OF SEXUAL DESIREHEADACHES (NOT MIGRAINES)MOOD SWINGSCONSTIPATIONDIARRHEADIGESTIVE BLOATING/DISCOMFORTNONE

Email Address*

GENDER

AGE

WEIGHT*

HEIGHT

MENSTRUAL STATUS

First day of last menstrual period:

Are your menstrual periods irregular?

How long is your menstrual cycle(days between day starting?

How many pads or tampons do you use on your heaviest day?

How old were you when you began menstruation?

ADDITIONAL GYNECOLOGICAL HISTORY

Do you have breast tenderness, discharge or a lump?

Have you had a mammogram? if yes, when?

Have you had an abnormal pap smear or positive HPV?

Have you taken estrogen, oral contraceptives or other hormones?

Current method of birth control:

HRT or other menopausal use?

PREGNANCY HISTORY*

Total number of pregnancies*

Live births:*

Miscarriages?

Abortion(s)?

Premature births?

PAST SURGICAL PROCEDURES (date and location)

PAST MEDICAL-HOSPITAL/EMERGENCY ROOM ADMISSIONS

CANCER HISTORY, SELF AND FAMILY

PAST MEDICAL HISTORY - SELF

High Blood PressureHigh cholesterolHeart DiseaseBlood clots in legs or lungsLung/Respiratory IllnessStroke/TIADiabetesThyroid DiseaseKidney DiseaseGallbladder DiseaseOsteoporosisSeizuresPsychiatric Illness, Dementia, Alzheimer'sVisual or Hearing Problems

PAST MEDICAL HISTORY- FAMILY

High Blood PressureHigh CholesterolHeart DiseaseBlood clots in legs or lungsLung/Respiratory IllnessStroke/TIADiabetesThyroid DiseaseLiver DiseaseKidney DiseaseGallbladder DiseaseOsteoporosisSeizuresPsychiatric Illness, Dementia, Alzheimer'sVisual or Hearing Problems

ALLERGIES

MEDICATIONS

SUPPLEMENTS

LIFE STYLE

Cigarette use? If yes, number per day? How long have you smoked this number per day?

History of drug use or abuse?

Describe sleep habits-- hours per night.

Describe your dietary habits.

List other medical history or life style habits that impact your health and well being.

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H O M E
A B O U T U S
H O R M O N E S
P E L V I C P A I N
M E D I T A T I O N
D O C U M E N T S
P A T I E N T H I S T O R Y
PATIENT INSURANCE

H O M E
A B O U T U S
H O R M O N E S
P E L V I C P A I N
M E D I T A T I O N
D O C U M E N T S
P A T I E N T H I S T O R Y
PATIENT INSURANCE

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LIFEPOINT INSTITUTE FOR WOMENDenard M. Fobbs, M.D.

PATIENT HISTORY

LIFEPOINT INSTITUTE FOR WOMEN
Denard M. Fobbs, M.D.