770-979-4700
Patient Portal
Request Appointment
Coronavirus (COVID-19) Patient/Visitor Policy
Learn More
Our Physicians
Physicians
Sabrina O. Falkner
Kimberly A. Huynh
Melissa O. Iyoyo
Sashana S. Gordon
Nurse Practitioners
Anna Pollard
Sydney Montgomery
Alexandra Norris
OB/GYN Services
OB Services
GYN Services
In-Office Procedures
Patient Center
Your Guide to Pregnancy
Patient Forms
Insurance
Directions
Contact Us
Menu
Menu
Medical Questionnaire
You are here:
Home
1
/
Medical Questionnaire
Medical Questionnaire Type
Annual
GYN/OB
Please answer all questions, if a question does not apply, place NA on that line
Name
*
First
Last
Date of Birth
*
MM slash DD slash YYYY
Please list one main reason for visit today:
What is the first day of your last period?
How many days does your cycle last, on average?
Is the flow:
Light
Medium
Heavy
What method of birth control are you currently using?
Are you postmenopausal?
Yes
No
If yes, what year did you transition?
What medications are you currently taking, including over the counter medicines and vitamins?
Medication
Dosage/Strength
Preferred pharmacy name and location:
Please list any allergies or drug sensitivities AND what reaction occurred?
Allergies/Drug Sensitivities
Reaction
Have you had a Mammogram since your last visit?
Yes
No
If yes, when?
Month
Day
Year
Have you had a Colonoscopy since your last visit?
Yes
No
If yes, when?
Month
Day
Year
Have you had a Dexa scan since your last visit?
Yes
No
If yes, when?
Month
Day
Year
Have you had any major illnesses, health changes or surgery, since your last visit? Please be specific.
Have you had any changes in family health history, since your last visit? Please be specific.
What is your current occupation/job title?
Relationship Status:
Single
Dating
Engaged
Married
Separated
Divorced
Widowed
Same-sex
Alcohol Use:
Light
Heavy
Former
Never
Tobacco Use:
Yes
Former
Never
If yes, how many per day?
If former, what age did you quit?
Recreational Drug Use (Marijuana, etc.):
Yes
Former
Never
Exercise:
Yes
Sedentary
Active, but no formal excercise
How many days per week?
Do you desire STD screening with today’s visit?
Yes
No
Have you had the Gardasil vaccine?
Yes
No
If yes, have you completed the series of all 3?
Yes
No
Consent
*
In case of an emergency, I consent to a blood transfusion.
Signature
Date
Month
Day
Year
Scroll to top
New Appointment Request
Your Name
*
Your Email
*
Your Phone
*
Requested Appt. Date
*
MM slash DD slash YYYY
