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Health Screening test details
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When was your last Pap smear
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Have you ever had abnormal pap?
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Details of abnormal Pap smear
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When was your last mammogram
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Mammogram results
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When was your DEXA(bone scan)
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DEXA showed
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When was your colonoscopy?
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Colonoscopy showed
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Current health status
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Are you currently pregnant?
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Whats the first day of your last period?
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Menstrual h/o
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Are you sexually active?
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Any sexual problems?
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Sexual preference
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Birth control
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Medical history
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Select all medical problems that you have been diagnosed with
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Additional medical problems
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Select surgeries that you have had
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Additional surgeries
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List medications with dosage you are taking
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List supplements you are taking
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List any allergies to medications
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Select all medical problems family members have
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Additions medical problems in the family
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Any h/o cancer in the family
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Any other cancer
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Obstetrical h/o
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Total pregnancies
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Miscarriages
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Abortions
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Total children
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Social h/o
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Do you smoke?
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Any past h/o smoking
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Do you drink alcohol?
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If yes to alcohol, how many drinks a week
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Do you take any illicit drugs?
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If yes, what do you take?
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