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Please print out this question format and fill it. Then bring it with you to our clinic.
Name ( )
- first middle last
- Sex (Female Male)
- Nationality Date of birth / /
- Age ( )
- Address
- Home phone
- Occupation
- Company
- Work phone
- Height ( ) cm Weight ( ) kg
- Medical history
-
- Record of past pregnancy and delivery:
- Have you ever been pregnant? (yes no)
- If yes, please fill in the blanks below:
- full term ( ) premature ( ) artificial abortion ( )
- miscarriage ( )
- Concerning menstrual periods:
- the last menstrual period was from (month) ( ) (day) ( )
- Menarche at ( ) years. Interval ( ) days. Duration ( ) days.
- Menopause (yes no) at ( ) years.
- The purpose of your visit:
- circle one (pregnancy, abnormal menstruation, discharge, itching,
- Pap test, abnormal urination, pain, contraception consultation)
- others ( )
- How long has this bothered you?( )
-
- Do you have any allergies?
- (yes no)
- If yes, please circle.
- food ( )
- drug ( )
- others ( )
-
- Have you ever smoked?
- (yes no) (yes, but gave up smoking at age )
- If yes, when did you start smoking?
- ( )year old
- How many cigarettes do you smoke a day?
- ( )
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copyright 2002.Oguri Ladies' Clinic All Rights
Reserved.
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