<p> HOW HAVE YOU BEEN DOING? Date____/___/____ Please let us know about any changes you’ve had in your life since we last saw you. Thank you!!</p><p>The reason for my visit today:______</p><p>______</p><p>Medication Dose Allergy and Sensitivities Contraceptive used: Address ______Drug Type reaction ______ I take hormones: ______Phone:______work Phone: ______I take supplements: ______vitamins Email ______calcium ______fiber ______herbal  I would like Email updates ______ ______</p><p>Date of first day of LAST MENSTRUAL PERIOD ___/___/___ Special concerns I would like Dr. to address: usually my periods are ___ days apart and I flow ___ days ______I have been missing my periods ______I have been having extra bleeding ______I suspect I may be PREGNANT ______I have pain with my period ______My menstrual flow is different ______last dental check: ___/___/___ last eye exam ___/___/___ Last thyroid check __/___/___ Last cholesterol level ___/___/___ Last tetanus shot ___/___/___Last flu vaccine ___/___/___  had chicken pox  had hepatitis vaccination I have sexual relations I have problems with my skin I have had some problems with sex I have unwanted facial hair I have pain during sex I have freckles or skin marks that have changed I’m worried I may have a sexual infection (STD) I have vaginal discharge I have headaches I have vaginal / vulvar bumps/ lesions/ sores I have vision hearing problems I have vaginal dryness I have sinus problems I have rectal bleeding irritation I have dental problems I have had an abnormal pap I have heart breathing chest problems I have had an abnormal mammogram I feel something different on my self breast exam I have abdominal pain  swelling I have nausea vomiting diarrhea constipation I leak urine daily I wear pads My stool is a different color shape I urinate too frequently I have had a lot of bladder infections I have  back  pelvic  leg pain  My legs are swelling  my joints are swollen  I have nerve problems  I have a recent injury  I have trouble sleeping  I want to quit smoking ___cigarettes/ day I have seen my other doctors since I have been here ____/___/______drinks/ week _____cups coffee/day _____ glasses water/ day ___/___/______</p><p> I have questions to ask the doctor in private</p>