UPDATE FORM
Name: _________________________ Date: _____________ Doctor: _____________________
Date of Birth: __________ Ethnicity: ___________ 1
st
day of your last menstrual period: _______
Why are you seeing the doctor/nurse practitioner today? _______________________________
(Please check all that apply to you TODAY)
seY lacigolocenyG seY TNEH
csid lanigaV sehcadaeH harge/irritation/odor
gnideelb ralugerrI taorht eroS
Breasts
Painful periods
esruocretni lufniaP spmul tsaerB
niaP civleP egrahcsid elppiN
niap tsaerB
Skin
Cardiovascular
Genital sores/bumps
spmul denialpxenU niaP tsehC
encA noitatiplaP traeH
Respiratory
Musculoskeletal
niaP kcaB gnizeehW
niaP tnioJ hguoC
htaerb fo ssentrohS
Endocrine
Gastrointestinal
Weight loss
niag thgieW niap lanimodbA
aesuaN
Psychological
yteixnA gnitimoV
noisserpeD noitapitsnoC
gnipeels ytluciffiD aehrraiD
skcatta cinaP loots ni doolB
Change in bowel habits
HEME/Lymph
Genitourinary
Easy bruising
gnideelB ysaE noitaniru lufniaP
eniru gnikaeL
Allergic/Immunological
reveF yaH ycnegru yranirU
noitsegnoc suniS ycneuqerf yranirU
eniru ni doolB
Constitutional
eugitaF )thgin/semit erom ro 2 gnitaniru( airutcoN
reveF
sllihC
CURRENT MEDICATIONS (prescription, over the counter, vitamins, birth control, herbs etc)
Name Dosage (mg) Frequency Date Started Prescribing MD
(continued on back)
ALLERGIES (drugs, foods, latex) REACTION
Any changes in your period: _____________________________________________________________
Do you have sexual intercourse? Yes No
If yes, how do you prevent pregnancy? _________________________________________
If yes, do you have/have you had a new sexual partner since your last exam? : Yes No
Medical Problems (changes since last visit): ________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
Surgeries (changes since last visit, include surgeon’s name and date): _____________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Major Changes in your life: ______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Tobacco/Cigarettes Use: Never Quit (date)__________
Current smoker ____packs/day, X ____yrs
Alcohol Use: No Yes
# ______ drinks per week ( beer wine liquor)
Is alcohol use a concern for you or others?
Yes No
Drug Use: No Yes
If so, what drug(s)_____________________
Exercise: Do you exercise regularly Yes No
If no, why not? ______________
If yes, what kind of exercise____________________________
How often? ____________How long? ______________
Diet: How do you rate your current diet? Good Fair Poor
Changes to health of a family member: _____________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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