C. Leslie Smith MS MA MD
Name:
Page 1 of 4
DOB:
Date:
Address:
Phone:
H:
C:
SSN:
Email:
Reason for visit today:
Referred by:
Are you currently using pharmaceutical medications?
If Yes, Please List:
Yes
No
Allergies:
Primary care physician:
Other provider(s):
Family Medical History
Your Present and Past Medical History
Urinary Tract Infections
Breathing Problems
Infection(s)
past)
Other History
Disorders
Pacemaker or Irregular
Heartbeat
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C. Leslie Smith MS MA MD
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Lifestyle Habits
Alcohol
Smoking
/week
Marijuana
packs/day
Illicit substances
/week __________/week
Supplements
____________/week
Exercise?
Please Describe
Please describe your typical diet for each meal. Note between-meal or late night snacks as well.
Breakfast
Lunch
Dinner
Gynecological
• Clots
• Pale Color
• Light Flow
• Normal Color
• Bright Red Color
Age when menstruation began
• Bleeding Between
Periods
• Irregular cycle
• Breast Tenderness
Date of last menstrual period
• Back Pain Related
to Cycle
• Menstrual Cramps
• Breast Lumps
Date and result of last Pap smear
• PMS
•Uterine Fibroids
• Vaginal Odor
At what age did you undergo
menopause
If undergoing menopause now, what are your symptoms?
Number of Pregnancies
Number of Live Births Number of Premature
Births


Length of Period:
Length of Cycle:

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Days
Days
Heavy Flow
Number of Induced
Abortions
Number of
Miscarriages
C. Leslie Smith MS MA MD
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Gan
Lump in
ails
the Throat
Tightness
in the Chest
Tearing
Pain
Pi
Lack of Taste
Abdominal Pain 
Foggy Thinking
Bleed or Bruise Easily
Loss of Appetite
Bloating 
Heavy Limbs
Vaginal Discharge

Excessive Saliva
Diarrhea 
Fatigue
Edema 
Flatulence
Hemorrhoids
Worry
Muscle Weakness
Loose Stools


Prolapse
Xin
orning
Shen
Libido
Afternoon and/or Evening
ircles Under Eyes
Concentration
Knees and Ankles
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C. Leslie Smith MS MA MD
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Fei
Spontaneous Sweating
Chest
Breathing when
Lying Down
Wei
Clear Fluid
Gums
Bile (green)
(GERD)
Blood
Dan
Da Cheng
Distention
Abdomen
atigue after Passing Stool
Number of bowel movements per day
Pan Guang
rinate Often
Urination
stones
Version: 10/11