Family Healthcare of Fairfax, PC Patient Portal

Family Healthcare of Fairfax, PC

Please fill as completely as you can. If not sure, leave blank.

Name * Date of Birth: * Date of Visit: * Reason for Visit: Date of last gyn/ pap exam: Date of last mammogram: Have you ever had an abnormal mammogram or pap? If yes, what was your treatment?

MENSTRUAL HISTORY:

Date of last period: Period and Cycle length in days: Period Flow Concerns with PMS?

SEXUAL HISTORY:

Sex of partner: Number of partners in the last 6 months: Pain with Intercourse? Bleeding with intercourse? Bleeding between periods?

PREGNANCY/ CONTRACEPTION:

Include Number of pregnancies, miscarriages, and abortions: Did you ever have diabetes during pregnancy? Pregnancy Complications? Concerns about fertility? Current plans for pregnancy? Current form of contraception: If other, please list what form: Satisfied with current form of contraception? Concerns about menopause? Difficulty with:

MEDICAL HISTORY:

Check those which YOU have had: Check those which your PARTNER has had: Is there anything else you would like to discuss at your visit? Do you need any refills? If yes, please list below.