OB/GYN Associates of the Merrimack Valley

JOHN C. HUGHES, M.D., KIRAN C. RAJU, D.O., and CYNTHIA COUGHLIN, CNM

295 Varnum Avenue, Lowell, MA 01854

PH: 978-452-2121 FX: 978-452-9371

INTAKE FORM

NAME: AGE: DOB:DATE:

Please fill out the information below in preparation for your visit. Record any changes that have occurred since your last appointment. List any new problems that you have had since your last visit:

Recent Labs, X-Ray or Surgery:

List all medications and dosages:

List any vitamins or herbal remedies:

Do you have any allergies:YES NO

Explain:

Any changes in your families medical history? YES NO

Explain:

Date of last period:Pain? YES NO Regular / Irregular

Type of contraceptionInterested in changing? YES NO

Do you do a self breast exam? YES NO

Do you have any concerns with sexual activity? YES NO

Explain:

Have you had any problem with vaginal discharge or infection? YES NO

Explain:

Do you exercise? YES NO How often

What type of exercise?

Do you wear a seatbelt? YES NO

Have you had a flu shot vaccine? YES NO

Have you had any problems with your bowels? YES NO

Explain:

Have you had any urinary tract concerns? YES NO

Explain:

Are you a smoker? YES NO How many per day?

Do you drink alcohol? YES NO What is your estimated daily alcohol intake?

Do you have a good appetite? YES NO

Do you have difficulty sleeping? YES NO

1) Constitutional
Weight Loss
Weight Gain
Fever
Fatigue / Currently / Past / Notes
2) Eyes
Double Vision
Spots Before Eyes
Vision Changes
3) ENT/Mouth
Ear Aches
Ringing in Ears
Sinus Problems
Sore Throat
Mouth Sores
Dental Problems
4) Cardiovascular
Painful Breathing
Chest Pain
Difficulty Breathing on Exertion
Swelling of Legs
Palpitations of Heart
5) Respiratory
Wheezing
Spitting Up Blood
Shortness of Breath
Cough, chronic
6) Gastrointestinal
Diarrhea, frequent
Bloody Stool
Nausea/Vomiting
Constipation
7) Genitourinary
Blood in Urine
Pain with Urination
Urgency
Frequency of Urination
Incomplete Emptying
Stress Incontinence
Abnormal Periods
Painful Intercourse
8) Musculoskeletal
Muscle Weakness
9) Skin/Breast
Pain in Breast
Discharge
Masses
Rash
Ulcers
10) Neurological
Dizziness
Seizures
Numbness
Trouble Walking
11) Psychiatric
Depression
Crying, frequent
12) Endocrine
Dry Skin
Abnormal Thirst
Hot Flashes
13) Hematological/Lymphatic
Bruises, Frequent
Cuts do not stop bleeding
Enlarged Lymph Nodes
14) Allergic/Immunologic
Allergies
Drugs, other