Submit Patient Information - The Jacksonville Fibroid Center

Patient Information

Date*

Name*

First Middle Last

D.O.B*

Age*

Referring Doctor

Reason For Visit*

Symptoms

Do you experience any of the following?*

Other Symptoms Not Listed

Please check any methods you have used to help with your symptoms

Birth Control
IUD (intrauterine device)
Pain Medications

Other Methods Not Listed

Fibroid History

Is there a family history of fibroids?*

Yes
No

Which family member?

Mother
Sister(s)
NONE

Bleeding History (Check all that apply)

Take an iron supplement for low blood count (anemia)*

Yes
No

Required a blood transfusion for low blood count (anemia)*

Yes
No

Average number of pads / tampons per day?

Average number of days in menstrual period?

Average number of days between menstrual periods?

Have you ever been prescribed or use the following medications?*

Have you received blood-thinning medications such as heparin or lovenox before or after a procedure?*

Yes
No

Gynecology History

Number of pregnancies*

Have you ever had a miscarriage?*

Yes
No

Do you desire to become pregnant again in the future?*

Yes
No

Date of last pap smear?

Results of pap smear?

Have you ever been treated for a sexually transmitted disease (STD)?*

Yes
No

Social History

Do you smoke?*

Yes
No

Please tell us about your occupation? If retired, please tell us about your previous work.

Marital status*

Married
Single
Divorced
Widowed

Medications (please list ALL medications, dose and reason)

Do you take antibiotics before dental or invasive procedures?

Yes
No

Do you have a communicable disease such as hepatitis or HIV?

Yes
No

Do you have a hole in your heart such as Patent Foramen Ovale (PFO) or Atrial Septal Defect (ASD)?

Yes
No

Medical History (Please list ALL past or present medical problems)

Past Surgical History (Please list ALL past surgeries and include year of procedure)

Review Of Systems (please check ALL that apply)

Constitution

Weight Loss
Weight Gain
Night Sweats
Fever

Skin

Change in size/color of moles
Rash
Bruising

Eyes

Decreased Vision
Double Vision
Blurred Vision
Glasses

ENMT

Cardiac

Respiratory

Cough
Production of sputum
Coughing of blood
Pain

Gastro

Genito

Musc/Skel

Weakness Trauma
Limited Motion
Bone / Joint Deformity

Neuro

Psych

Anxiety / Depression
Hallucinations

Endocrine

Change of appetite
Excessive thirst / urination
Goiter

Hematology

Swollen lymph nodes
Bleeding disorders

Immuno

Immune disorders
Immunosuppressant

Name

This field is for validation purposes and should be left unchanged.