Woods & Water Medical Center

Rice Lake, WI
Questionnaire
Patient name

Review of Systems

MHN

Taking birth control pills

Excessive vaginal discharge
Post menopausal
Contraception
Breast feeding

Age

Gender

Yes

Frequent/Severe headaches/migraines
Ear aches/drainage
Frequent bloody noses
Difficulty swallowing
Hoarseness
Shortness of breath
Persistent cough
Chest pain
Heart disease/murmur
Hypertension
Insomnia
Swelling legs/ankles/edema
Palpitations/Irregular heart beat
Abdominal/Stomach pain/indigestion
Nausea
Vomiting
Diarrhea
Constipation
Rectal bleeding/Hemorrhoids
Black bowel movement/melena
Jaundice/Liver trouble
Coordination/Balance changes/mobility
changes
Difficulty bathing/dressing
Frequent nighttime urination/nocturia

Gynecological History

DOB

Yes

Burning/Other difficulty urinating

Bladder/Kidney infection/Sepsis
Kidney stoned/Nephrolithiasis
Convulsions/Seizures
Fainting spells/dizziness
Joint pain/arthritis/Gout
Back trouble
Nervousness
Depression
Family/Sexual problems
Unusual fatigue/weakness/lethargy
Weight loss
Skin rashes
Vision changes/loss
Hearing loss/ringing in ears/tinnitus
Lumps/Knots/Swelling
Unusual bruising/bleeding
Heat/Cold intolerance
Hair loss
Breast lumps/masses
Numbness/Tingling
Memory/Concentration
changes/dementia
Nose dry/congested

Yes

Yes

Bleeding between menstrual periods

Excessive bleeding during menstrual
period
Hot Flashes
Estrogen replacement

Month and year of mammogram

Month and year of last pap

Start date of last period

Age at first period

Number of pregnancies

Number of children born alive

W&W Medical Center, 1900 College Drive, Rice Lake, WI 54868

Created 4/9/2015