Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 5Please complete this patient information survey to the best of your knowledge & ability. Please leave any sections blank if you are unsure or uncomfortable answering. The purpose of these questions is to recognize a holistic range of factors which may affect your care, and to help us identify and meet your individual health needs. This survey will become part of your confidential medical record. Thank you! **Consent to transmit patient information and my signature electronically. *I agreeI do not agree (Please close form and contact office)All data submitted through this form electronically will be treated in accordance with our privacy policy and will be encrypted and stored securely. PERSONAL INFORMATIONPatient Name *FirstLastDate of Birth *Age *Email *NextMEDICAL HISTORYDo you have any allergies?YesNoPlease list any allergies (latex, medications, foods, etc.)Are you currently taking any prescriptions, vitamins, supplements?YesNoPlease list all current prescription medications, as well as any vitamins/supplements you use on a regular basis.Did you receive this year's seasonal flu vaccine?YesNoHave you had the COVID vaccination?YesNoWould you be interested in getting a COVID vaccination?YesNoApproximate date and location (please specify name of medical office/facility) of your last pap (write NA if you have never had a pap)?Approximate date and location (please specify name of medical office/facility) of your last mammogram (write NA if you have never had one)?Do you see another healthcare provider or office for primary care needs/annual exams?YesNoPlease indicate your PCP and approximate date of last visit.Please indicate if you have/had the following (check all that apply):AsthmaEczema or PsoriasisBlood TransfusionKidney StonesFibroidsGenital HerpesAbnormal PapChickenpoxMigrainesGI Disease: GERD, IBS, pancreatitis, or IBD (Crohns, colitis)Chronic pain or FibromyalgiaGallbladder stones and diseasePCOSHave you had any other STI's (Chlamydia, gonorrhea, trich, HIV, syphilis) or PID?YesNoDon’t knowDid you have a colposcopy, cryotherapy, LEEP, or conization?YesNoDon’t knowPlease indicate if you or your blood relatives (parents, grandparents, siblings, children, aunts/uncles) have been affected by the following conditions (check all that apply):Thyroid disease (ie. Hashimoto, Graves)Hypertension (high blood pressure)Diabetes (including gestational diabetes)High cholesterolMental illness (including depression, anxiety, eating disorder, postpartum depression, PTSD)Uterine fibroidsPreterm delivery (<37 wk)OsteoporosisBlood clot (DVT, PE)Autoimmune disease (ie lupus, MS, RA)SeizuresKidney diseaseLiver disease (including hepatitis)Heart disease (ie. heart attacks, bypass surgeries, arrhythimia)StrokeThrombophilia (ie. Factor V Leiden)Thalassemia, sickle cell, or hemophiliaAutism spectrum or other developmental delayOther genetic disease, chromosomal disorder, or birth defectCancerFor all conditions that are selected above please provide who, age of onset, and any additional notes.Please list any surgeries you have had & approximate year of procedure.Have you had any hospital admissions other than for surgeries listed above, or childbirth?YesNoPlease provide details of other hospital admissions you have had in the past.Have you had other medical issues? Any notes to include on entries above?NextGYN & REPRODUCTIVE HEALTHAge at first Menarche (first period)Are you currently menopausal?YesNoWhat age did you become menopausal?1st day of last menstrual period: Are you certain of this date?YesNoLength of Menstrual Cycle: Every __ days (measured from 1st day of one period to 1st day of next period; i.e. every 28 days or 21-38 days if irregular)Have you received the HPV vaccine (Gardasil, Cervarix)?YesNoAre you currently sexually active?YesNoDo you have or have you had sex with men, women, or both?MenWomenBothHave you had any new sexual partners since your last GYN exam?YesNoAre you interested in being screened for sexually transmitted infections (STIs)?YesNoDo you use condoms for STI protection?AlwaysSometimesNeverDo you use contraception/birth control, or take measures to avoid pregnancy?YesNo, I am trying to conceiveNo, or only sometimes, but I am open to pregnancy if it occurredNo, and I would like to obtain birth controlNo, I do not get a period or I am menopausalNo, I am not with a male partnerWhich contraceptive method do you use now?NexplanonBirth control pillsNuvaRing or PatchCondomsDiaphragmPartner had vasectomyTubal ligationIUDWithdrawal/partner pulls outFertility awareness/Natural family planning/Calendar methodAre you satisfied with your method of birth control?YesNoPlease explain why are you not satisfied with your method of birth control.Indicate if you have any of the following GYN concerns (check all that apply):Heavy mensesPMS/PMDDPainful intercourseIrregular bleeding or periodsUnusual dischargeBreast lump or changesPainful periodsPelvic painLow libidoUrinary incontinence or leakingRecurrent (>2 per year), Yeast, UTIPeri-menopause/Menopausal symptoms (hot flashes, night sweats, vaginal dryness)Have you ever had, or been diagnosed with any of the following (check all that apply):PCOSFertility treatmentEndometriosisOvarian cystsHave you had any miscarriages?YesNoHow many miscarriages have you had in the past?Have you ever terminated a pregnancy (had an abortion)?YesNoHow many abortions have you had in the past?Have you ever had an ectopic pregnancy?YesNoHow many ectopic pregnancies have you had in the past?Have you ever had a molar pregnancy?YesNoHow many molar pregnancies have you had in the past?Have you given birth previously? YesNoFor each birth you have had previously, please provide the requested information below. 1st Birth-Please note name, birth date, sex, gestation age (# weeks pregnant), labor length, delivery type (vag or C/S), delivery weight, and birth location (city, state, home birth, etc.)2nd Birth-Please note name, birth date, sex, gestation age (# weeks pregnant), labor length, delivery type (vag or C/S), delivery weight, and birth location (city, state, home birth, etc.)3rd Birth-Please note name, birth date, sex, gestation age (# weeks pregnant), labor length, delivery type (vag or C/S), delivery weight, and birth location (city, state, home birth, etc.)4th Birth-Please note name, birth date, sex, gestation age (# weeks pregnant), labor length, delivery type (vag or C/S), delivery weight, and birth location (city, state, home birth, etc.)Additional Births-Please note name(s), birth date(s), sex, gestation age(s) (# weeks pregnant), labor length(s), delivery type(s) (vag or C/S), delivery weight(s), and birth location(s) (city, state, home birth, etc.)Are all of the children you gave birth to currently living?YesNoDo all of your children who you have given birth to have the same father?YesNoIf you had a C-section: Please note why it was done if you know the reason.Please note if you had any complications with previous deliveries (i.e. postpartum hemorrhage, shoulder dystocia, 4th degree tear, use of forceps, placental abruption, etc.)NextSOCIAL HISTORY & LIFESTYLEWhat is your relationship status (single, married, divorced, partnered, etc.)?Occupation (job, student, stay-at-home mom, etc.)?Living situation: who shares your home (roommates, husband & kids, dogs/cats, etc.)?Indicate the highest level of education you have completed.Some high schoolHigh school diplomaSome collegeUndergraduate degreeGraduate degreePlease note any dietary restrictions (ie. vegetarian, vegan, gluten-free, Kosher, etc.)Do you exercise?Regularly (nearly every day)Sometimes (1-2x per week)Rarely (less than once per week)NeverWhat do you like to do for exercise?Do you currently, or have you ever, smoked cigarettes regularly?YesNoWhat age did you begin smoking?How much do you currently smoke?If you quit smoking, when did you quit? to of needs/annual Do you currently use marijuana?YesNoHow often do you drink alcohol?Regularly (nearly every day)Sometimes (1-2x per week)Rarely (less than once per week)NeverOn a day that you drink, how many alcoholic beverages do you have?Have ever had a substance use disorder?YesNoDid you ever seek help (ie. AA/NA program, opioid treatment, etc.)?YesNoHave you ever experienced domestic violence, sexual assault, or abuse?YesNoDo you currently feel safe in your home?YesNoIf you have children, do you have full custody of your children?YesNoDo you belong to a religious community, tribe, otherwise hold cultural/spiritual beliefs which might affect your care?YesNoPlease provide more information about the beliefs that might affect your care. Please note any additional information about your responses in this section.NextADDITIONAL INFORMATIONHow did you hear about Southwest Midwives? (If you heard of us through a friend or relative, please share the name of the person who referred you!)Is there anything else you would like us to know, or to address with you at our first meeting?Thank you for taking the time to fill out this form and welcome to Southwest Midwives! Submit
