Full Form GET STARTED We are a team that believes in creating a great experience from start to finish and go lengths to provide personal care throughout your visit. Name Email Address Cell Phone DateBirth Age Occupation Current Weight Height BMI Referring Person SURGERY SUGGESTED Doctor Jaime Ricardo Ramos Kelly M.D. Name Relationship Address Cell Phone Name Sex Select Male Female Prefer not to say Other Select Date of Birth Marital Status Select Single Married Divorced Widowed Separated Domestic Partnership Select Date of last physical exam Height Current Weight Childhood illness Chickenpox Tetanus Hepatitis Influenza MMR Measles Mumps Rubella List any medical problems that other doctors have diagnosed Surgeries Have you ever had a blood transfusion? Select Yes No Not sure Select List your prescribed drugs and over-th- -counter drugs, such as vitamins and inhalers: Name the Drug. Reaction You Had? Exercise Select No regular exercise Mild exercise (e.g., climb stairs, walk short distances, golf) Moderate exercise (e.g., run, swim, bike occasionally) Heavy exercise (e.g., daily gym workouts, sports training) Are you dieting? Yes No of meals you eat in an average day? Rank salt intake Select Low Moderate High Select Rank fat intake Select Low Moderate High Select Caffeine consumption Select Coffee Tea Energy drinks None Select Do you drink alcohol? Yes No If yes, what kind? How many drinks per week? Are you concerned about the amount you drink? Yes No Have you considered stopping? Have you ever experienced blackouts? Select Yes No Not sure Select Are you prone to "binge" drinking? Select Yes No Not sure Select Do you drive after drinking? Select Yes No Occasionally Prefer not to say Select Do you use Tobacoo? Cigarettes Chew (smokeless tobacco) Pipe Cigars No Number of years? Do you currently use recreational or street drugs? Select Yes No Prefer not to say Select Have you ever given yourself street drugs with a needle? Select Yes No Prefer not to say Select Are you sexually active? Select Yes No Prefer not to say Select If yes, are you trying for a pregnancy? Select Yes No Prefer not to say Select If not trying for a pregnancy list contraceptive or barrier method used? Any discomfort with intercourse? Yes No Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness? Yes Yes Do you live alone? Yes No Do you have frequent falls? Yes No Occasionally Do you have vision or hearing loss? Physical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider? Yes No Is stress a major problem for you? Select Yes No Sometimes Select Do you feel depressed? Yes No Sometimes Do you panic when stressed? Yes No Sometimes Do you have problems with eating or your appetite? Do you cry frequently? Yes No Sometimes Have you ever attempted suicide? Have you ever seriously thought about hurting yourself? ¿Tienes problemas para dormir? Have you ever been to a counselor? Yes No Father: Mother: Siblings Grandparents Age at onset of menstruation: Date of last menstruation: Heavy periods, irregularity, spotting, pain, or discharge? ¿Número de embarazos? Number of live births? Are you pregnant or breastfeeding? Yes No Have you had a D&C, hysterectomy, or Cesarean? Any urinary tract, bladder, or kidney infections within the last year? Any blood in your urine? Any problems with control of your urination? Yes No Sometimes Any hot flashes or sweating at night? period? Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period? Yes No Sometimes Experienced any recent breast tenderness, lumps, or nipple discharge? period? Date of last pap and rectal exam? Do you usually get up to urinate during the night? Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain. -Ears Yes No Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain. -Nose Yes No Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain. -Throat Yes No Recent Changes In:- Weight Recent Changes In:- Energy Level Recent Changes In:- Ability to Sleep How did you hear about us?-Other Friend or Family Doctor Referral Social Media Google / Website Advertisement Other Please let us know the other way you heard about us. I have read and accept the Privacy Notice. Send
