Mark W. Hinman, MD, LLC
1350 Tulip Street, Longmont, Colorado

PAP SMEAR QUESTIONAIRE                                       Patient Name:__________________________

Age _____ Last Pap _____ Any abnormal Pap Smears (yr and dates)_____________________

Last period ______________ usual Length_______ Usual interval between Periods _________

Amount of menstrual flow: Circle) Light Moderate Heavy; Age of onset of Menses ___________

Number of Pregnancies _____ Number of Deliveries _____

Number of Miscarriages _____ Number of Living Children _____

Type of Birth Control _____ Last Mammogram _____

CURRENTPROBLEMS/CONCERNS: _______________________________________________________________

_____________________________________________________________________________________________

PAST HISTORY:

Hospitalizations ________________________________________________________________________________

Surgery & Major Illnesses ________________________________________________________________________

Significant Medical Problems ______________________________________________________________________

Special Procedures ______________________________________________________________________________

FAMILY HISTORY: _____________________________________________________________________________

SOCIALHISTORY:

Family_______________________________Work ____________________________________________________

Activities____________________________Diet ______________________________________________________

Alcohol____________________ Tobacco _____________________ Caffeine _______________________________

Drugs______________________ Exercise ___________________________________________________________

HEALTH MAINTAINANCE: Date of Last Check

Blood Screen_____________ EKG ______________________ Physical _______________________

Colon Cancer Screen_______ Tuberculine Test _________ Immunizations (DT) _____________

MEDICATIONS: ____________________________________________________________________________________

ALLERGIES: _______________________________________________________________________________________


System Review

Yes

No

Explain all yes answers

Too frequent/few periods

      

Irregular bleeding or spotting

      

Significant pain with periods, or intercourse

      

Problems with premenstrual tension

      

Unusual vaginal discharge and/or itching

      

Breast tenderness, lump, or discharge

      

Painful or frequent urination

      

Loss of urine control

      

Blood in urine

      

Blood from rectum or black tarry stools

      

Blood clots, varicose veins, anemia

      

Kidney or thyroid disease

      

Chest pain, shortness of breath, palpitations

      

Unusual cough, wheezing, or breathing problems

      

Unusual skin lesions, change in color, or itching

      

Abdominal pain, indigestion constipation, or hepatitis

      

Pain or swelling of muscles, bones or joints

      

Abnormal weakness, numbness, stress or depression

      

Fevers, weight changes, sleep problems, or headache problems

      

 

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