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Women's Services PATIENT INTERVAL HISTORY & PHYSICAL FORM

Women's Services PATIENT INTERVAL HISTORY & PHYSICAL FORM 2025

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The document is a patient intake form for women's health services, designed to collect comprehensive medical history and current health information from patients. It includes questions about pregnancies, menstrual cycles, birth control methods, lifestyle habits (such as smoking and alcohol consumption), allergies, medications, and family medical history. The form aims to assist healthcare providers in understanding the patient's health status and needs.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal information at the top, including the date, your name, and contact numbers. This ensures that your healthcare provider can easily reach you.
Proceed to section 1, where you will provide details about your pregnancy history. Fill in the total number of pregnancies and any miscarriages.
In section 2, list your primary care physician and insurance details. This helps streamline communication with your healthcare team.
If applicable, answer questions regarding your menstrual cycle in sections 3 through 8. Be as detailed as possible to give a clear picture of your reproductive health.
Continue through sections 9 to 21, addressing any health concerns or lifestyle habits such as smoking, alcohol consumption, and exercise frequency.
Finally, review all entries for accuracy before submitting the form. This ensures that all information is correct for optimal care.

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