Get the free well woman information sheet 2017 - Abundant Health Family Practice
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Please complete items 1 through 11 (2 pages front and back)WELSHWOMAN EXAM Name Today's Date of Birth 1. Age: e. A new or enlarging lump in breastYESNOf. Change in size/firmness of stoolsYESNOg. Change
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How to fill out well woman information sheet
How to fill out well woman information sheet
01
Start by entering your personal information such as name, age, date of birth, and contact details.
02
Provide your medical history, including any past surgeries, illnesses, or chronic conditions you may have.
03
Fill in any medications you are currently taking, including the dosage and frequency.
04
Specify any allergies or adverse reactions you may have to medications or substances.
05
Provide details about your menstrual cycle, including the date of your last period and any irregularities you may experience.
06
Answer questions about your sexual activity, including contraception methods used and any history of sexually transmitted infections.
07
Mention any family history of specific medical conditions such as breast or ovarian cancer.
08
Include information about your lifestyle habits, such as smoking or alcohol consumption.
09
Complete the form by signing and dating it to certify the accuracy of the provided information.
Who needs well woman information sheet?
01
Any woman who is visiting a healthcare provider for a routine check-up or a specific issue related to their reproductive health may need to fill out a well woman information sheet.
02
This form helps the healthcare provider gather essential information about the individual's medical history, current health status, and any potential risk factors that might affect their reproductive health.
03
The well woman information sheet is particularly important for women seeking preventive care, prenatal care, family planning services, or screening for conditions like cervical cancer.
04
It assists the healthcare provider in evaluating the individual's overall health, identifying potential concerns, and providing appropriate care and recommendations.
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