Established Patient Wellness

Patient First Name

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Patient Last Name

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Date

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Allergies:

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When?

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Do you have any concerns that you want to talk to your provider about today (please explain)?

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General gynecology update:

First day of last menses (if you have menstrual cycles)?

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days of bleeding?

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how often menses occurs?

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heavy bleeding?

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bleeding irregularly or between menses?

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Current method of pregnancy prevention (if any)?

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Are you in a sexual relationship? Problems or concerns with sexual health?

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Wellness questions:

Do you have a primary care physician? Name and date of last visit.

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Would you like to do wellness labs at your visit today?

Yes

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If appropriate:

When was your last mammogram? NA or

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When was your last colonoscopy? NA or

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When was your last bone density? NA or

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When was your last bone density? NA or

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

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Social update:

tobacco products (smoking, vaping, chewing)?

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alcohol consumption (drinks per week)?

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recreational drug use?

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Exercise habits (activity and days a week)

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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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