*Please provide the patient's full legal name as it appears on their driver's license, state identification card, or government issued identification card.
What is your smoking status?
How many packs per day do you smoke?
How many packs per day did you smoke?
How many years have you smoked?
How many years did you smoke?
Do you use other tobacco products?
Are you exposed to passive (secondhand) smoke?
Please answer yes or no if you or your partner have had any of the following: IV drug use, more than one sexual partner, unprotected sexual contact, contact with contaminated injection equipment, multiple blood transfusions, HIV or Hepatitis B.
How often do you wear a seatbelt?
Do you feel safe at home?
In the past year, have you been hit, punched, kicked or slapped by anyone?
*Do you have any surgical history?
*Do you have any medical history problems?
Length of flow (on average):
Cycle regularity (from 1st day of period to start of next period):
Current contraception (mark all that apply):
Prior contraception (mark all that apply):
Did you begin having sex before the age of 18?
Are you currently sexually active?
Are you planning a pregnancy this year?
Number of pregnancies (include current)
Number of vaginal deliveries
Number of cesarean sections
Number of ectopics (tubal pregnancy)
Have you had any complications?
*Do you have a family history of illnesses?
Osteoporosis / Osteopenia
Psychiatric care / Hospitalization