Well-Woman Exam
Patient Questionnaire
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Today's Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Any changes in contact or insurance information since your last visit?
No
Yes
First day of last menstrual period (or first year of mensuration, if through menopause)
If you are under age 55, what method of birth control do you use?
Are you planning a pregnancy in the next 6-12 months?
Yes
No
Do you have any of the following:
Rows
Yes
No
Sometimes
Problems with present method of birth control
1
2
3
Bleeding between periods or since periods stopped
4
5
6
Pain with intercourse or periods
7
8
9
Any problem with interest in or enjoying intercourse
10
11
12
A new or enlarging lump in breast
13
14
15
Change in size/firmness of stools
16
17
18
Change in size/color of a mole
19
20
21
Severe headaches
22
23
24
Pain in the leg, chest, abdomen, or joints
25
26
27
Trouble falling or staying asleep
28
29
30
Often feeling down, depressed, or hopeless during the past month
31
32
33
Often having little interest in doing things during the past month
34
35
36
Conflict in your family or relationships, sometimes handled by pushing, hitting, or cruelty
37
38
39
Have there been any changes to the following since your last visit?
Rows
Yes
No
Medications
40
41
Health History (migraines, asthma, hypertension, depression, high cholesterol, etc)
42
43
Health Maintenance (pap smear, eye exam, colonoscopy, mammogram, etc)
44
45
Surgical History
46
47
Social History (occupation, diet, tobacco use, alcohol use, etc)
48
49
Family Medical History
50
51
If you answered "yes" to any of the above, please explain:
Which of the following are included in your diet:
Rows
A Lot
Some
Few
None
Grains
52
53
54
55
Vegetables
56
57
58
59
Dairy foods
60
61
62
63
Meats
64
65
66
67
Sweets
68
69
70
71
Do you exercise regularly?
Yes
No
Exertion level?
Stroll
Mild
Heavy
If so, about how many days per week?
Time/duration?
Safety and Prevention
Rows
Yes
No
N/A
Unsure
Do you always wear a seatbelt?
72
73
74
75
If over 30 years old, have you had your cholesterol level checked in the past 5 years?
76
77
78
79
Have you had a tetanus shot in the past 10 years?
80
81
82
83
Does your house have working smoke detectors?
84
85
86
87
Do you have firearms at home?
88
89
90
91
Last time you had a dental check-up?
Last time you had a vision check up?
Please describe any questions or concerns you may have:
Please verify that you are human
*
Submit
Should be Empty: