Annual Exam Questionnaire
Patient name: ______DOB: ______
Referring Physician/Provider: ______Primary Care Provider: ______
Updated: 10/18/2018
Check if you are currently having any of the following problems.
Updated: 10/18/2018
Constitutional
Fever
Chills
Weight loss
Weight gain
Breasts
Breast pain
Breast lumps
Breast discharge
Cardiovascular
Chest pain
Palpitations
Leg swelling
Heart murmurs
Endocrine
Craving sweets
Excessive thirst
Heat/cold intolerance
Eyes/Ears/Nose/Throat
Pain
Colds
Headache
Sinusitis
Discharge
Nose bleeds
Gum disease
Hearing loss
Gastrointestinal
Pain
Bloating
Nausea/vomiting
Constipation
Diarrhea
Change in quality/character of stools
Blood in stools
Gynecologic
Excess bleeding
Painful periods
Menstrual cycle changes
Abnormal discharge
Unscheduled bleeding or spotting
Vulvar/vaginal lumps
Vulvar/vaginal itching
Loss of sexual interest
Pain or bleeding with intercourse
Urologic
Frequent urination
Urgency to urinate
Blood in urine
Pain or burning with urination
Loss of urine spontaneously
Loss of urine with sneeze or cough
Night urination
Hematologic/Lymphatic
Bruises
Bleeding
Craving ice
Swollen glands
Musculoskeletal
Swelling
Muscle weakness
Muscle or joint pain
Neurological/Psychiatric
Seizures
Depression
Severe anxiety
Lack of coordination
Suicide attempt
Excessive crying
Difficulty with memory or speech
Skin
Rash
Itching
Hair loss
Excess hair growth
New or changed mole/lump
Updated: 10/18/2018
When was your last menstrual period? (m) ______(d) ______(y) ______
Are you sexually active? NO YES If so, have you changed sexual partners? NO YES Sexual partner preference? Male Female
Method of birth control: ______
Have you ever had an abnormal pap smear? NO YES Date of last pap smear? ______
Do you exercise regularly? NO YES What kind? ______
Do you smoke? NO YES How much? ______
Do you use recreational drugs? NO YES What kind? ______
Do you drink alcohol? NO YES How many drinks per week on average? ______
Date of last mammogram: ______Date of last bone density test: ______
Date of last colonoscopy: ______Was it: Normal Polyps Other: ______
Date of last cholesterol check: ______Last tetanus shot? ______
What is your current job? ______Since your last visit, have you lost a loved one? NO YES
Since your last visit here, has an immediate family member been diagnosed with: diabetes osteoporosis
heart attack under age 50 cancer of the: breast colon uterus ovary pancreas
______
VITAL SIGNS—TO BE COMPLETED BY NURSE
Updated: 10/18/2018
Weight: ______
Height: ______
Hgb: ______
BP: ______/______
Pulse: ______
Respiration: ______
Temp.: ______
Urine: ______
Updated: 10/18/2018