PATIENT INTAKE HISTORY

Please fill out the following form to help us understand your physical condition.

If you are here for an annual examination is this a:
Is this a new problem?

GYNECOLOGIC HISTORY

SEXUAL PARTNERS ARE
HAVE YOU EVER USED AN INTRAUTERINE DEVICE (IUD) OR BIRTH CONTROL PILLS?
HAVE YOU EVER HAD AN ABNORMAL PAP TEST?
DO YOU DO REGULAR BREAST SELF-EXAMINATIONS?

OBSTETRIC HISTORY

CURRENT MEDICATIONS

(Include hormones, vitamins, herbs, nonprescription medications)

FAMILY HISTORY

Mother:
Father:

Siblings:

Children:

ILLNESS

DIABETES
STROKE
HEART DISEASE
BLOOD CLOTS IN LUNGS OR LEGS
HIGH BLOOD PRESSURE
HIGH CHOLESTEROL
OSTEOPOROSIS
HEPATITIS
HIV/AIDS
TUBERCULOSIS
BIRTH DEFECTS
DRINKING OR DRUG PROBLEM
BREAST CANCER
COLON CANCER
OVARIAN CANCER
UTERINE CANCER
MENTAL ILLNESS/DEPRESSION
ALZHEIMER'S DISEASE
OTHER

WHICH RELATIVE & AGE OF ONSET

SOCIAL HISTORY

EVER SMOKED?
ALCOHOL
RECREATIONAL DRUG USE
SEAT BELT USE
REGULAR EXERCISE
DAIRY PRODUCT INTAKE/CALCIUM SUPPLEMENTS
HEALTH HAZARDS AT HOME OR WORK?
HAVE YOU BEEN SEXUALLY ABUSED, THREATENED OR HURT BY ANYONE?

PERSONAL PROFILE

SEXUAL ORIENTATION
MARITAL STATUS
HIGHEST LEVEL OF EDUCATION COMPLETED
TRAVEL OUTSIDE THE US?

PERSONAL PAST HISTORY OF ILLNESS

ASTHMA
KIDNEY INFECTIONS/STONES
SEXUALLY TRANSMITTED DISEASE
HEART ATTACK/PROBLEMS
HIGH BLOOD PRESSURE
RHEUMATIC FEVER
EATING DISORDER
CHICKENPOX
REFLUX/HIATAL HERNIA/ULCERS
ANEMIA
SEIZURES/CONVULSIONS/EPILEPSY
GLAUCOMA
ARTHRITIS/JOINT PAIN/BACK PROBLEMS
HEPATITIS/YELLOW JAUNDICE/LIVER DISEASE
GALLBLADDER DISEASE
PNEUMONIA/LUNG DISEASE
TUBERCULOSIS
HIV/AIDS
DIABETES
STROKE
BLOOD CLOTS IN LUNGS OR LEGS
COLLAGEN VASCULAR DISEASE (LUPUS)
CANCER
DEPRESSION/ANXIETY
BLOOD TRANSFUSIONS
BOWEL PROBLEMS
CATARACTS
BROKEN BONES
THYROID DISEASE
HEADACHES

OPERATIONS/HOSPITALIZATIONS

INJURIES/ILLNESSES

IMMUNIZATIONS/TEST

REVIEW OF SYSTEMS

PLEASE SELCT ANY OF THE FOLLOWING SYMPTOMS THAT APPLY TO YOU NOW OR SINCE ADULTHOOOD

WEIGHT LOSS
WEIGHT GAIN
FEVER
FATIGUE
CHANGE IN HEIGHT

If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse. 

Dr. Mona Hardas

Obstetrics & Gynecology

Our Address

Email: hardasobgyn@gmail.com
Tel: 810.720.1790

Fax: 810.337.1170
3353 Fleckenstein Dr

Flint, MI 48507

Clinic location
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Office Hours

Monday through Thursday: 8 a.m. to 5 p.m.
Friday: 8 a.m. to 1 p.m.
Saturday and Sunday: CLOSED

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