Dr. Sheona M. Mitchell-Foster

MD MPH FRCS (C)

Obstetrician Gynecologist

Please fill the intake form below.

First Name *

Last Name *

Street Address *

APT, Suite, Unit

City *

Postal Code *

Primary Phone *

Family Doctor *

Height *

Weight *

Reason for referral *

Preferred pronoun *

she/her

he/him

they/them

other

(please check one)

Preferred Pharmacy *

Pregnancy History

Date

Number of weeks

Miscarriage/ termination/ delivery type

Please describe any complications

Gynecologic History

Date of last menstrual period *

Are your periods regular *

Yes No

Length of your period

Please select number of days

How heavy is your flow *

Spotting Light Regular Heavy

How many days do you bleed for *

Number of days between periods *

Do you ever experience bleeding/spotting between periods? *

Yes No

Menopausal symptoms *

Yes No

Hot flashes *

Yes No

Vaginal drynes *

Yes No

Date of last Pap smear

Abnormal Pap smears *

Yes No

Vaccinated against HPV *

Yes No

Date of last mammogram

Do you ever leak urine *

Yes No

Have you had gynecologic problems or surgeries in the past *

Yes No

Example: fibroids, cysts, endometriosis

Do you have problems with *

Bowels

Bladder

Bulge/prolapsed

Pelvic pain

None

Are you sexually active *

Yes No

Do you have concerns with sexual functioning *

Yes No

Are your partner(s) *

Men

Women

Both

None

Current method of birth control *

Prior sexually transmitted infections

Medical and Surgical History

Have you ever had problems with any of the following? (Please check all that apply)

Headaches

Neurologic condition

Stroke

Seizures

Blood clots

Bleeding disorder

Arrhythmia

Heart attack

Structural heart problems

High Cholesterol

Hypertension

Obesity

Asthma

COPD

Other lung disease

Sleep Apnea

Weight gain

Weight loss

Chronic pain

Interstitial cystitis

Depression

Psychiatric condition

Kidneys

Bladder

Bowels

Fibromyalgia

Irritable bowel syndrome

Crohns/Colitis

Liver disease

Gallbladder

HIV

Hepatitis C

Hepatitis B

Gynecologic Cancer

Other Cancer

Thyroid

Other medical conditions not listed above

Please list all prior surgeries

Current Medications (please list medication and dosage)

Allergies (please list)

Social History

Your work

Your partners name

Your partners work

Number of alcoholic beverages per week

Smoke cigarettes *

Yes No

Number of cigarettes per day

Quit date if smoked in the past

Other drug use

Family History (please check all that apply, provide details if you can)

Breast cancer

Ovarian cancer

Uterine cancer

Colon cancer

Bleeding disorders

Blood clots

Heart attack

Other

Is there anything else you would like Dr. Mitchell-Foster to know

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