Patient Intake Form

Please fill out the patient intake form before you come in for your first appointment with Dr. Dae. This will allow her to be more prepared for your appointment with her.

First Name *

Last Name *

Address

City

State

Postal code

Country

Country

Email *

Cell Phone *

Date of birth

Gender

Marital Status

Occupation

Employer

Name of Spouse

Name of Children

Name of Emergency Contact

Phone number of emergency contact

Who Referred you to the practice *

List All Health Concerns in Order of Importance *

Medications

List any medications that you are currently taking

List Vitamins or Supplements you are currently taking

Have you taken antibiotics in the last year?

Please list allergies ( food or environmental) you are aware of

Medical / Health History

Height

Weight gain

Has your weight changed more than 10 pounds in the last 6 months

Primary Care Provider

Doctor's Phone

Date of last full physical exam

Any abnormal results or abnormal labs?

List any serious illnesses/Major Accidents/Surgeries

Family History

Please check if you or a member of your family has a history of any of the following diseases

Allergies

Self

Mother

Father

Grandparent

Sibling

Alcoholism

Self

Mother

Father

Grandparent

Sibling

Anemia

Self

Mother

Father

Grandparent

Sibling

Anxiety

Self

Mother

Father

Grandparent

Sibling

Arthritis (Rhematoid)

Self

Mother

Father

Grandparent

Sibling

Arthritis (Osteo)

Self

Mother

Father

Grandparent

Sibling

Cancer

Self

Mother

Father

Grandparent

Sibling

High Cholesterol

Self

Mother

Father

Grandparent

Sibling

Depression

Self

Mother

Father

Grandparent

Sibling

Diabetes

Self

Mother

Father

Grandparent

Sibling

Epilepsy

Self

Mother

Father

Grandparent

Sibling

Heart Disease

Self

Mother

Father

Grandparent

Sibling

Hepatitis

Self

Mother

Father

Grandparent

Sibling

High Blood Pressure

Self

Mother

Father

Grandparent

Sibling

Kidney Disease

Self

Mother

Father

Grandparent

Sibling

Mental Disorders

Self

Mother

Father

Grandparent

Sibling

Nervous Disorders

Self

Mother

Father

Grandparent

Sibling

Obesity

Self

Mother

Father

Grandparent

Sibling

Stroke

Self

Mother

Father

Grandparent

Sibling

Thyroid Disorder

Self

Mother

Father

Grandparent

Sibling

Order Disease not mentioned

Dietary/Lifestyle

Coffee

Tobacco

Alcohol

Drugs

Antacids

Daily

Weekly

Occasionally

Never

Aspirin *

Red Meats *

Chicken *

Fish

Vegetables *

Fruits *

Dairy *

Water *

Daily

Weekly

Occasionally

Never

Starch - Rice/potatoes *

Sodas/Sweet beverages *

Wheat - Bread *

Chips/Nachos *

Cereal *

Desserts/Sweets

Do you use a special diet? What does it consist of?

Please rate you stress level for the following *

My work life is joyous and easy

My home life is joyous and easy

My relationship with my significant other is joyous and easy

My relationship with my children is joyous and easy

My health related concerns are joyous and easy

My extracurricular activities are joyous and easy

What time do you typically go to sleep?

Do you fall asleep right away?

What time do you wake up?

Do you hit the snooze button? How many times?

Do you wake rested?

Exercise Habits

How many days a week do you exercise?

For how long do you typically exercise

What form(s) of exercise do you participate in

Do you have any exercise restrictions

WOMEN'S HEALTH HISTORY

What was the age you started menstruating?

What was the first day of your last period?

How long did it last?

Is your cycle regular?

Do you use? (Check all that apply)

Tampons

Pads

Cups

How many do you use on your heaviest day

Do you get premenstrual symptoms?

When do they occur in your cycle?

Premenstrual Sypmtoms

Please rate the severity of your premenstrual symptoms

Breast Tenderness

Bloating

Skin/Acne

Appetite Changes

Headache

Cramping

Diarrhea/Constipation

Mood Changes

Low Back Pain

Other Symptoms:

Do your symptoms get better with your flow

Do you have vaginal discharge or irritation?

Do you have recurring vaginal or bladder infections?

How frequently are your infections?

Have you had any recent gynecological exams? What year?

Do you have a current or past history of:

Herpes

Venereal wart

Venereal disease

Who is current gynecologist?

Have you ever had fibroids? How Many? What Size?

Breast History

Do you have a history of

Discharge

Breast Tenderness

Swelling

Fibrocystic Breast

Breastfeeding

If so, How long did you breast feed?

Menopause

What age did you start menopause?

Do you have hot flashes? How often?

Do you have any of the following symptoms:

Night Sweats

Insomnia

Palpitation

Depression

Anxiety

Vaginal Dryness

Irregular bleeding

Decrease in sexual drive

Acne

Loss of Memory/Cognition

Osteoporosis

Facial hair and Hair Loss

Birth Control

What forms of birth control have you used or are using

Abstinence

Vasectomy

Tubal ligation

Hysterectomy

IUD

Diaphram

Condoms

Cervical cap

Foam

Condoms

None

Pill Name - Number of years taken

Any questions or problems concerning sex or intercourse?

Number of Pregnancies

Number of Miscarriages

Number of Abortions