New Patient Health History

Patient Information

First Name*

Middle Initial

Last Name*

Date of Birth

Phone Number (including area code)

E-mail Address*

Any new sexual partners in the past eight weeks? Yes No

Age periods began?

Are you still having periods? Yes No

Are you currently using any form of contraception? Yes No

Sexual History

Have you ever had sexual intercourse? Yes No

What is your sexual preference?

Surgical History

Hysterectomy

Type of Hysterectomy

Removal of Ovary(s)

Both Ovaries Right Ovary Only Left Ovary Only One Ovary - Unsure which side

Breast Biopsy

Right Breast Left Breast Both Breasts

Mastectomy

Right Breast Left Breast Both Breasts

Other Breast Surgery & Treatment

Radiation
Chemotherapy
Breast Reconstruction

Mammogram History

Have you ever had a Mammogram? Yes No

Last Mammogram Date

Results

Do You Have Implants? Yes No

Any History of Breast Cancer? Yes No

Any Family History of Breast Cancer? Yes No

Any History of Mastectomy?

Any History of Biopsy?

Bone Mineral Density Testing History

Have you ever had BMD Testing? Yes No

Last BDM Date

Results

Colonoscopy History

Have you ever had a Colonoscopy? Yes No

Last Colonoscopy Date

Results

Allergies

Do you have a latex allergy? Yes No

Do you have a peanut allergy? Yes No

Allergy #1 Reaction

Allergy #2 Reaction

Allergy #3 Reaction

Allergy #4 Reaction

Allergy #5 Reaction

Allergy #6 Reaction

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Surgical History

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Your Health History has been sent.

Office Hours:

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