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Medical History Form

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Section 1: Personal Information

Name First Last	Home Phone - (###) - ### ####
Email	Cell Phone - (###) - ### ####
Contact Preference	Work Phone - (###) - ### ####
Preferred time of day to be contacted

Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Date of Birth - MM/DD/YYYY

Ethnicity

If other ethnicity, please specify

Age

Height Feet

Height Inches

Weight (lbs)

Sex

Profession
Treatment Needs Pain Infertility Obstruction Adhesions Other
If other treatment needs, please specify

Section 2: Areas of Pain

My worst pain area is
My usual pain level in this area is	Pain is

Pain is Dull Aching Sharp Shooting Burning Tight Pressure

My next worst pain area is
My usual pain level in this area is	Pain is

Pain is Dull Aching Sharp Shooting Burning Tight Pressure

Other pain areas include
My usual pain level in this area is	Pain is

Pain is Dull Aching Sharp Shooting Burning Tight Pressure
Because of my symptoms or condition, I cannot do the following things:

Medical History

Bladder Infection	Pelvic/Adominal Pain	Hormonal Problems	Difficulty Sitting
Kidney Infection	Digestive Problems	Cardiovascular Disease	Physical Disability
Kidney Stones	Intestinal Problems	Liver Disorder	Polyps
Interstitial Cystitis	Constipation	Diabetes	Neurological Disorder
Vaginal Infection	Thyroid Problems	Diarrhea	Headaches
STD or Herpes	Endometriosis	Gall Stones	Allergies/Sinusitis
Infertility	PCOS	Lymphedema	Other
If other, please specify

Section 3: Contraindications

How many partial SBOs do you think you have ever had?
How many full SBOs have you had in your life?
How many times have you been hospitalized for SBO-related symptoms?
How many SBO-related surgeries have you had in your life?
About what date did you last have SBO symptoms?
How frequently do you get SBO symptoms or scares? times per
Has your physician indicated that you will likely need another SBO surgery?
Can you eat solid food without having adverse symptoms?
Do you have an active infection, hemophilia, or HIV?
If yes, please explain
Do you currently have or have you ever had cancer?
If yes, please explain (date / location / type / size / treatments / stage 1-4 / remission)

Section 4: Surgery and Trauma History

Please include DATES and explanations for any surgery and/or trauma you have undergone.
The below list is for reference.

Surgery to the cervix	Hysterectomy	Laparotomy (open surgery)
Bladder repair	Fractures	Adhesion removal (lysis)
Pelvic Surgery	Episiotomy	Laparoscopy
Tummy Tuck	Fibroid	Appendectomy
Gall Bladder	C-Section	Pins, plates, or screws inserted
Bowel obstruction	D&C or abortion	Genital Mutilation
Car Accidents	Physical/Sexual Abuse	Falls to tailbone, back, hip
Hit on head/back	Radiation therapy

Have you had problems or complications from any surgeries or traumatic injuries?
If yes, please explain
List diagnostic tests you've had regarding present or past medical complaints (give dates & diagnosis)
I experience pain with

Intercourse Urination Bowel Movements Erections Other
If other, please explain
Have you ever been told you have adhesions/scars?
Were you treated for adhesions/scars?
How were you treated?

Section 5: For Females Only

Males skip to Section 7

Do you currently have any ovarian cyst(s)?
If yes, what are present cyst(s) location and size?
Present cyst(s) are
How many pregnancies have you had? (Number / outcome ex. full-term / tubal / miscarriage / abortion / D & C)
Have you ever had an IUD (intrauterine device)?
Do you presently have an IUD (intrauterine device)?

During sex, I have decreased

Desire (libido)

Arousal

Lubrication

Orgasm

I have pain with intercourse ______% of the time.
I experience pain with my menstrual cycle
If yes, explain (pre-menstrual, period related, ovulatory)

Section 6: For Infertile Females Only

Males skip to Section 7

Hormone Levels:

FSH	Estrogen	Progesterone
LH	Estradiol	Thyroid

Are you presently undergoing any treatments for infertility?
If yes, explain
Describe past infertility treatments, dates and outcomes
Tell us what you know about your reproductive system Fallopian tube (right):

Functional Scarred Blocked Removed Unsure
Fallopian tube (left):

Functional Scarred Blocked Removed Unsure
Ovaries:
Uterus:

Section 7: Goals for Therapy

My goals for therapy include: (e.g. fertility, pain relief, improved bowel or other functions)
Is there anything else you'd like to ask or we should know?

Please submit your completed medical history form.

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Postal mail it to 4421 NW 39th Ave. Suite 2-2, Gainesville, FL 32606.

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