Established Patient Problem Visit

Patient First Name

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Patient Last Name

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Date:

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Allergies:

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What brings you to our office today?

Problem visit (please explain)

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Are you having any urinary symptoms such as burning with urination, urinary frequency, or uri

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Are you having any excessive or irregular vaginal bleeding?

Yes

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Please Explain:

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Do you think you may be pregnant?

Yes

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If you have menstrual cycles, what was the first day of you last menses?

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What is your method of pregnancy prevention (in any)?

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Have you had any changes to your personal health, surgeries or family health since your last visit at Athens OB/GYN?

Yes

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Please Explain:

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Current medicines: (or provide list):

NAME

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STRENGTH

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INSTRUCTIONS FOR DOSING

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NAME

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STRENGTH

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INSTRUCTIONS FOR DOSING

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NAME

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STRENGTH

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INSTRUCTIONS FOR DOSING

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