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Search for:
Providers
Nahla Merhi, M.D.
Judy Sun, M.D.
Julie Bright-Allot, MSN, FNP-C
Staff
Register
Patient Registration
Patient Medical History
Education
Patient Testimonials
Services/Procedures
Urogynecology
Robotic Surgery
da Vinci Gynecologic Procedures
da Vinci Hysterectomy
Benign Gynecologic Conditions
Early Stage Gynecologic Cancer
da Vinci Vs. Open & Laparoscopy Surgery
da Vinci Myomectomy
News
Offices/ Affiliations
Insurance
Patient Medical History
Michael Zorko
2019-06-11T10:31:48-05:00
Online History Form
Patient Information
Name
First
Last
Date Of Birth
Date Format: MM slash DD slash YYYY
Age
Weight
Height
Chief Complaint
Email
Please enter your email address if you would like a copy of the completed form emailed to you upon completion.
Next | Medical History
Medical History
Please select all that apply below
Allergies
Anemia
Anxiety
Asthma
Bipolar Disorder
Bladder Problems
Blood Disorder
Breast Problems
Cancer
Depression
Diabetes
Digestive Problems
Heart Disease
Hepatitis
High Blood Pressure
High Cholesterol
HIV/AIDS
Infertility
Kidney Problems
Liver Disease
Seizure Disorder
Stomach Problems
Thyroid Problems
Other
Please list
In the previous question you answered other. Please add additional history separated by a coma.
Allergies
You listed selected allergies above. Please list them here.
Next | Previous Surgeries
Previous Surgeries
Type of surgery and dates
Previous Surgery
Date Of Surgery
Please list the type of surgery and the date of surgery. To list an additional surgery click on the plus sign.
Next | Previous Hospitalizations
Previous Hospitalizations
List hospitalizations and dates
Hospitalization/Reason
Date
Please list the reason for hospitalization and date. To list an additional hospital stay click on the plus sign.
Next | Current Medications
Current Medications
Medication
Strength
Dosage
Please provide us with medication, strength and dosage on each line. To add a new medication please click on the plus sign.
Immunizations
Gardasil
Yes
No
Unknown
Have you had the Gardasil Vaccine?
1st Injection
Please provide the month and year of your first injection
2nd Injection
Please provide the month and year of your second injection
third Injection
Please provide the month and year of your 3rd injection
Next | Social History
Social History
Smoker
Yes
No
Former
How many years?
How many cigarettes a day?
Alcohol
Yes
No
Frequency
Socially
Ocasionally
Daily
Drugs
Yes
No
Which Drugs
Exercise
Yes
No
How many times a week?
Next | Gynecological History
Gynecological History
Please indicate "yes" or "no" along with dates and duration of all that apply.
When was your last menstrual cycle?
Date Format: MM slash DD slash YYYY
PMS Symptoms
Abnormal Menstrual Bleeding
Yes
No
N/A
Heavy Periods
Yes
No
N/A
Have you ever had a pap smear?
Yes, I have had a pap smear in the past
No, I have never had a pap smear
When was your last pap smear?
Date Format: MM slash DD slash YYYY
Have you ever had an abnormal pap smear?
Yes
No
What was the abnormal result and when?
When was your last mammogram?
Date Format: MM slash DD slash YYYY
Have you ever had an abnormal mammogram?
Yes
No
What was abnormal?
Any abnormal vaginal discharge?
Yes
No
For how long?
Are you currently sexually active?
Yes
No
Are you on any birth control?
Yes
No
Which One?
Any history of sexually transmitted diseases (STD)
Yes
No
Which One(s)?
Problems with sexual functions/arousal?
Yes
No
Please describe
Do you experience pelvic pain with?
Intercourse
Menstrual pains that impact your life
Bowel Movements
Other
No/None of the above
Next | Pelvic Pain Questionnaire
Next | Obstetrical History
Pelvic Pain Questionnaire
Based on your response to the previous question, we ask that you complete the following questionnaire on pelvic pain.
Do you experience any of the following complaints?
Painful periods that require you to miss school or work
Yes
No
Have they been getting worse?
Yes
No
Have you been treated or evaluated for this in the past?
Yes
No
Do you experience pain with intercourse?
Yes
No
Do you avoid intercourse because of pain?
Yes
No
Is the pain with initial penetration?
Yes
No
Is the pain deep in the vagina/pelvis during sex?
Yes
No
Do you have pelvic pain/throbbing after sex?
Yes
No
Can you localize your pain during intercourse?
Yes
No
Does the pain impact your quality of life?
Yes
No
Is your pain/discomfort aggravated by tight clothing?
Yes
No
Are you unable to use tampons because of the pain?
Yes
No
Next | Obstetrical History
Obstetrical History
Have you ever been pregnant?
Yes
No
How many times?
How many living children?
Deliveries by C-Section?
Vaginal Birth?
Are you planning on having children in the near future?
Yes
No
Maybe
Next | Urinary & Bowel History
Urinary & Bowel History
Do you have a history of recurrent bladder infections?
Yes
No
Do you currently have any of the following when urinating?
Burning (Yes)
Frequency (Yes)
Urgency (Yes)
None of the above
Please choose any that apply
Do you currently have any involuntary loss of urine upon:
Sneezing (Yes)
Coughing (Yes)
Running (Yes)
None of the above
Please choose any that apply
Do you experience involuntary loss of gas or stool?
Yes
No
Next | Family History
Next | Urinary Questionnaire
Urinary Questionnaire
You have answered yes to at least one of the questions on the previous page. Please complete this questionnaire to continue.
In the past 12 months have you experienced any of the following?
Loss of urine when you laugh, cough, sneeze or exercise
Yes
No
How often?
Daily
Occasionally
Rarely
Do you leak urine with intercourse?
Yes
No
Do you have to wear a pad because of your leakage?
Yes
No
Do you find it a problem that you urinate very frequently?
Yes
No
Are you constantly looking for the nearest bathroom?
Yes
No
Do you find yourself avoiding certain activities so you don't have to urinate oftern?
Yes
No
When you feel the need to urinate...
Is it associated with a strong sense of urgency, that you have to run to the bathroom?
Yes
No
If you cannot reach the bathroom, will you experience an accident?
Yes
No
Do you awaken at night to urinate?
Yes
No
How often?
How many times a day do you urinate?
After voiding, do you feel like your bladder is not completely empty?
Yes
No
Do you experience pain when you urinate?
Yes
No
Is the pain worsened by intercourse?
Yes
No
Have you tried any medications for your urinary symptoms?
Yes
No
Next | Family History
Family History
Breast Cancer:
Please specify, yourself and/or immediate family member
Ovarian Cancer:
Please specify, yourself and/or immediate family member
Endometrial Cancer:
Please specify, yourself and/or immediate family member
Stomach/Colon Cancer:
Please specify, yourself and/or immediate family member
Other:
Please specify, yourself and/or immediate family member
Other:
Please specify, yourself and/or immediate family member
Are you over the age 50 or currently Menopausal?
Yes
No
Next | Over 50 Questionnaire
Next | Complete Form
If over 50 years of age or Menopausal
You answered yes to the final question on the previous page. Please take a moment to complete the following questionnaire before completing the form.
Do you experience hot flashes?
Yes
No
Do you experience sexual dysfunction?
Yes
No
Please explain
Do you experience vaginal dryness?
Yes
No
Date of last colonoscopy
Date Format: MM slash DD slash YYYY
Result
Normal
Abnormal
What was abnormal?
Date of last bone scan
Date Format: MM slash DD slash YYYY
Result
Normal
Osteopenia
Osteoporosis
Do you take calcium and/or vitamin D supplements?
Yes
No
How much?
Do you have a history of bone fractures?
Yes
No
Is there a family history of hip fractures?
Yes
No
Who in your family?
Have you taken steroids for more than 3 months at a time?
Yes
No
Have you ever received chemotherapy in the past?
Yes
No
Next | Complete Form
Complete Form
Thank you for completing the patient history form. Please feel free to take a moment and review your submission. You can do so by using the navigation buttons below. Once you are satisfied with the completed form simply submit the form using the button below. A copy of the completed form will be emailed to you upon completion. Thank you.
