Dr Carol I. Lynn Gynecology

​​​​Call Us: 901-755-2900


CLINICAL INFORMATION HOPE HEALTH Date __________ Name ____________________________Date of birth_____________ List all medications (including dosage) you are currently taking: (Please include vitamins, supplements and herbs, etc.) ________________________________________ ___________________________________________ __________________________________ ____________________________________ __________________________________ ____________________________________ Allergies or Drug reactions: _________________________________________________ Food intolerance or dietary restrictions: ________________________________________ ________________________________________________________________________ Operations: Year Procedure ________ _______________________ ________ _______________________ ________ _______________________ Hospitalizations: When Reason _________ ________________________ _________ ________________________ _________ ________________________ Major Accidents: _________________________________________________________ _______________________________________________________________________ Ongoing Health Issues (ie: hypertension, diabetes, thyroid disorder,etc…): ___________ _______________________________________________________________________ Reason for Today’s Visit: _______________________ ________________________ _______________________ ________________________ _______________________ ________________________ General: Marital/Domestic Status____________ Employer/Occupation___________________ Do you have children? How many_______ Number of times you exercise weekly______ Are you a smoker? Y N How many per day? ____ Ready to quit? Y N Do you use street drugs? Y N Number of alcoholic drinks per week _______ Have you ever had a sexual encounter you did not want? Y N Other specialists/Health Care Providers or Alternative Therapist and/or Therapies: _________________________________________________________________________ _________________________________________________________________________ Most Recent Immunizations (Please note year received)/Examinations: Tetanus ________ Flu shot________ Last physical exam (mo/yr) ___/_____ Colonoscopy (mo/yr) ___/_____ Chest x-ray________ EKG______ Bone Density___/_______ If over 60: Pneumovax __________ Tetanus ____________________ Women only: Date of last Pap smear (mo/yr) ____/______ Mammogram (mo/yr) ____/______ Do you have a Living Will (a document that tells us what medical care/life support you want or do not want if you become irreversibly ill)? YES ___NO ___ Do you wish to be an organ donor? YES ___NO _

Initial History – Page 3 FAMILY HISTORY:  Anemiac  Arthritisc  Asthmac  Alcoholismc  Allergiesc  Cancerc  Depressionc  Diabetesc  Drug Usec  Epilepsy / seizuresc  Glaucomac  Heart Diseasec  High blood pressurec  High cholesterolc  Liver diseasec  Osteoporosisc  Mental illnessc  Pancreatitisc  Rheumatic feverc  Strokec  Tuberculosisc Other: __________________________________________________________________ Birthdate State of Health Medical Problems (or cause of death) Father: __________________________________________________________________ ________________________________________________________________________ Mother: _________________________________________________________________ ________________________________________________________________________ Brothers: ________________________________________________________________ ________________________________________________________________________ Sisters: _________________________________________________________________ ________________________________________________________________________ Spouse: _________________________________________________________________ ________________________________________________________________________ Children: _______________________________________________________________ _______________________________________________________________________ Grandparents (specify maternal/paternal and grandmother/grandfather): _____________ _______________________________________________________________________ _______________________________________________________________________ Aunts and Uncles related by blood (specify maternal/paternal): _____________________ ________________________________________________________________________ ________________________________________________________________________ Other: __________________________________________________________________ ________________________________________________________________________