Microsoft word - return h+p 100112.docx

HILO OBSTETRICS & GYNECOLOGY – QUYEN TRAN, M.D.

Name____________________________________ DOB ________________ Age_____ Date_____________
Reason for this visit:_________________________________________________________________________

Please circle all changes that apply to your health in the last 6 months:
□ No changes
GENERAL: weight gain or loss (____ lbs), fever or chill, decrease in strength or exercise tolerance. ENT:
vertigo, bleeding gums. HEART: chest pain, palpitation, passing out. LUNGS: shortness of breath, wheezing,
coughing up blood. ABDOMEN: difficulty swallowing, blood in stool, dark stool, dark vomit. MUSCLE:
limited range of motion, numbness or tingling. NEURO: tremor, seizure, difficulty with speech. PSYCH:
hallucination, change in thought content, suicidal ideation. BREASTS: lump, swelling, nipple discharge.
URINARY: pain with urination, urgency, frequency, hesitancy, incontinence, blood in urine.
GYNECOLOGICAL: vaginal discharge, odor, itching, painful intercourse, bleeding after intercourse

If you still have your periods, complete this section:
First day of last menstrual period:________________________. Age period began:____ .
Periods are usually (please circle): regular/slightly irregular/very irregular. Bleeding is: heavy/moderate/light. They are:
very painful/slightly painful/not painful. Bleeding last: ____ days
If you are entering or have already entered menopause, complete this section:
Age of menopause: _____. Circle any of these following symptoms that you are experiencing: hot flashes, night sweat,
vaginal dryness, loss of interest in sex, insomnia, mood swings, forgetfulness, or urine leakage.
Date of last Pap smears: _________________________ Date of last Bone density test:_______________________
Date of last Mammogram:________________________ Date of last Colonoscopy: _______________________________
Please list all changes from your last visit (new medical problems/surgeries/medications):
□ No changes
____________________________________________________________________________________________________________________________________________________________________________________
For office use only:
VS: Wt ___ Ht ___ Temp ____ BP _______ P ___ R____
UA: Blood __ Protein __ Nitrite __ Leuko__ Glucose__ Urine culture
UCG:____ WP: BV/Y/Trich Hemoccult: ___ Hgb:____ BG: ___
PAP GC/Ch STD MMG Colon DEXA U/S Lab______
Sprintec Nuvaring OrthoEvra Depo Provera
Macrobid/Cipro/Bactrim Flagyl/Metrogel Diflucan/Monistat/Nystatin Premarin PV/Prempro
NL Findings
GEN
NEURO □ ______________________ PSYCH □ ______________________ HEENT □ ______________________ HEART □ ______________________ LUNGS □ ______________________ EXT □ ______________________ ABD □ ______________________ BRSTS □ ______________________ PELVIC □ ______________________ Uterus ant/mid/post/absent

Source: http://www.hiloobgyn.com/forms/Form%20006-Returning%20HnP.pdf