Patient History
General Information
Mame: ______________________________ DOB: ___/___/_____
Address: ____________________________________
____________________________________
Phone: __________________ (Hours: ______________)
Email: ____________________________
Emergency Contact:
Name: _______________________ Relation _______________
Address: _____________________________ Phone: __________________
_____________________________ Phone: __________________
Email: ______________
Primary Physician:
Name: _______________________ Phone: __________________
Current Medications:
______________________________________________
______________________________________________
______________________________________________
Insurance:
Carrier: ______________________ Policy #: __________________________
Medical History
Enter name of condition and when it occurred.
Allergies:
Latex: __________________
Non-oxynol 9:_______________
Iodine: ____________________
Foods: ______________________
Bee Stings: ________________
Respiratory: ________________
Other: _____________________
Heart Conditions: ___________________
Respiratory Conditions: __________________
Broken Bones: _________________
Dislocations: __________________
Contact Lenses: _________________
Heartburn/Nausia: _______________
Siezure Disorder: ________________
STD's: Current Past
Herpes (oral): _______ _______
Herpes (vaginal/anal): _______ _______
HIV/Aids: _______ _______
Hepatitis: _______ _______
Clamidia: _______ _______
Gonorea: _______ _______
Syphilis: _______ _______
Genital/Anal Warts: _______ _______
Pubic Lice: _______ _______
Other: _______ _______
Bleeding/clotting problems: _____________________
Other oral problems: _____________________
Other genital problems: _____________________
Other rectal problems: _____________________
Other conditions: ______________________________________
______________________________________
______________________________________
______________________________________
Emotional Traumas:
Rape: _________________ Molestation/Abuse: __________________
Other: __________________________________________________
Treatment
Check boxes ("[ ]") for diagnostic services to be performed.
[ ] Urine Sample
Urinary Tract Infection: _______ pH: _______
Physical Measurements:
[ ] Height: _________
[ ] Weight: ________
[ ] Neck: _____ Wrist: ____ Forearm: _____ Upper Arm: ______
Bust: _____ (Cup size: ____) Under Bust: ______
Waist: _________ Hips: _________
Thigh: _________ Calf: _____ Ankle: _____ Inseam: _____
Shoe Size: ______ Dress Size: _______
[ ] Nipples (Normal): Diameter: __________ Length: _________
[ ] Nipples (Diameter): Diameter: __________ Length: _________
[ ] Temperature (oral): _____ [ ] Temperature (rectal): _____
[ ] Bload Pressure: Systolic: _____ / Diastolic: _____ Pulse: ______
[ ] Eye inspection
[ ] Visual (penlight/opthalmoscope)
[ ] Ear Inspection
[ ] Visual (ottoscope)
[ ] Swab
[ ] Throat Inspection:
[ ] Visual/Tung
[ ] Swab
[ ] Nasal
[ ] Visual (ottoscope)
[ ] Swab
[ ] Eye Exam (chart)
[ ] Hearing test (audiometer/tuning fork)
[ ] Breast Exam (lumps): __________
[ ] Feel for Tenderness/Pain
[ ] Face/sinuses
[ ] Breasts [ ] Abdomen [ ] Pelvis
[ ] Penis [ ] Testicles
[ ] Labia [ ] Clitoris [ ] Vagina
[ ] Blood test (finger prick)
[ ] Blood Glucose: ______
[ ] HIV: _______
[ ] Lung/Heart (Stethoscope)
[ ] Reflex test (taylor hammer)
[ ] Neurological test (Wartenberg Wheel)
[ ] Injection (fake)
[ ] Needles (Temp. piercing) Locations: __________________________
[ ] Electrical Stimulation (Tens) Regions: ___________
[ ] Electrical Stimulation (Violet Wand) Regions: ___________
[ ] Vaginal Exam
[ ] Restraints
[ ] Urethral Swab
[ ] Clitoral Swab
[ ] Speculum
[ ] Visual inspection
[ ] Cervical Swab
[ ] Rectal Exam
[ ] Hemoroids (Finger)
[ ] Dilation
[ ] Kiegel Exercises
[ ] Penetration
Fingers: [ ] Mouth [ ] Vagina [ ] Rectum
Toung: [ ] Mouth [ ] Vagina [ ] Rectum [ ] mammilary
Dildo: [ ] Mouth [ ] Vagina [ ] Rectum [ ] Inter-mammilary
Penis: [ ] Mouth [ ] Vagina [ ] Rectum [ ] Inter-mammilary
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