Patient Intake PATIENT INTAKE FORM The information below will be used by Dr. Gerber and Meridia Medical staff to better serve you and make your visit more efficient. Any information submitted will remain confidential, will not be released and will only to be reviewed by Meridia Medical staff members. This form is submitted using a SSL secure certificate Disclaimer:* Any fields with the *(star) are required to make our intake process easier.Personal InformationName* First Name Last Name Age*Birth Date* Date Format: DD slash MM slash YYYY Address* Street Address Apartment/Suite # City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Email* Home Phone*Work PhoneMobile Phone*Please check the telephone # we can use to contact you and to notify you of upcoming appointments:The number that you prefer we call firstHomeMobileWorkHealth Card #Health Card Expiry Date Date Format: MM slash DD slash YYYY Version Code: (The two letters following the ohip number)Which province is your health card from?OntarioQuebecPEINew BrunswickNewfoundland and LabradorManitobaSaskatchewanAlbertaBritish ColumbiaFamily DoctorReferring Doctor’s nameGynecological HistoryAge at your first period?Are you menopausal? (No periods for one year or more)YesNoSince when? Date Format: MM slash DD slash YYYY If Menopausal: Do you have hot flashes, insomnia, vaginal dryness etc? Are you using hormone replacement therapy? Have you had any vaginal bleeding/spotting/brown discharge? First date of your last period Date Format: DD slash MM slash YYYY How often are your periods? (In days)Are your periods regular?YesNoHow many days do you bleed?Are your periods painful?YesNoAre your periods heavy?YesNoDo you bleed between periods?YesNoDo you have bleeding after intercourse?YesNoDate of your last PAP smear Date Format: MM slash DD slash YYYY Has your PAP smear ever been abnormal?YesNoHave you had treatment for an abnormal PAP smear?YesNoWhat form of contraception do you use now?NothingCondomBirth control pillIUDTubal ligation / VasectomyHave you ever used a birth control pill?YesNoHave you ever used an IUD (Intra-Uterine Device)?YesNoHave you ever had a Pelvic Infection (PID)?YesNoHave you ever had any of the following infections?Check all that apply Herpes Chlamydia Gonorrhea Warts Hepatitis B or C Syphilis None Have you been tested for HIV(AIDS)?YesNoHave you had a mammogram?YesNoWhen last? Date Format: MM slash DD slash YYYY Have you had a bone density test?YesNoWhen last? Date Format: MM slash DD slash YYYY Obstetric HistoryHave you ever been pregnant?YesNoPlease list ALL pregnancies (Date and outcome):DateOutcome: (Miscarriage, Termination, Live Birth, Stillbirth etcMethod: (D&C, Vaginal delivery, Forceps, C-Section)SexBirthweightComments Medical HistoryPlease list ANY medical conditions you have/had: (e.g. Asthma, Diabetes, Thyroid, Hypertension, Depression)Type N/A if you’ve had none Are you on any medications?YesNoList ALL current medications:Name and dose please, including Herbal and Natural remediesMedication NameDosage Allergies to Medications:If allergic, please list all drug names and the reaction.Drug NameReaction Are you allergic to Latex?YesNoHave you ever had a BLOOD Transfusion?YesNoHave you ever had an operation?YesNoWhat was the reason and date of your operation?Name of operationDate Have you EVER been hospitalized for any reason other than above?YesNoPlease state the reason and date of hospitalizationReasonDate Do you smoke?YesNoHow many/day?Do you drink alcohol regularly?YesNoHow many/day?Family History: Any relatives with the following: (please indicate which relative.)(Heart Disease, Diabetes, Hypertension Bleeding Disorders, Breast Cancer, Birth Defects, Ovarian Cancer, Blood clots, etc)Condition/IllnessRelative Allergy: (please list all medications you are allergic to, as well as the type of allergy from the drop down list)Don't knowSkin Rash/ hives/itchAnaphylactic/throat swellingVomiting/stomach side effectsOthersOthersName of medications Allergy or reaction to General anaesthetic or Local anaesthetic/freezing None React or allergy to local anaesthetic/freezing React or allergy to General Anaesthetic Larger Genital Lips/Labia:Many woman experience changes in the shape of the labia (genital lips). Sometimes these are longer, unusually shaped or one side is larger than the other. Often times the inner labia grow larger over time. Women may find that these changes affect them during exercise, during intercourse or when they wear tight clothing, requiring readjustment as they walk etc. Some woman are just embarrassed about having larger labia and may avoid changing or showering at the gym in front of others or avoid intimacy and sexual relationships because of it. Often, there is a simple procedure that is commonly done at Meridia Medical to correct these changes. If you are interested and wish to learn more about this, please do not be embarrassed and let us know by indicating yes or noYesNoSexual HistoryMany women have problems that interfere with intercourse and sexual satisfaction.Although it might be embarrassing at first, often these can easily be treated. If you are comfortable answering these questions, we will try to help you.Are you sexually active?YesNoDo you have pain with intercourse?YesNoIs the pain on the outside or deep inside?At the entranceDeep InsideDo you have any problems with sexual relations?Check any that apply or let us know of any additional problems. Lack of desire Low satisfaction Low lubrication Lack of enjoyment/orgasm Additional problems:Please comment below on any other problems with sexual relations so we can help.Voiding and Prolapse HistoryOften women have problems with urine and bowel accidents. It is embarrassing and frustrating, and interferes with enjoyment of life. Fortunately, these can be treated well in 85% of cases.Do you have problems with passing/leaking urine?It is normal to leak urine occasionally especially during exerciseYesNoDo you leak urine/have accidents?YesNoDo you leak urine when coughing, laughing, sneezing, dancing, running etc? STRESS Incont:YesNoDo you have to run to the toilet urgently when you feel the urge to go? URGENCY:YesNoDo you sometimes leak before you reach the toilet bowl? URGE Incont:YesNoDo you just leak at any time, without warning? UNAWARE Incont:YesNoHow often do you urinate during the day? FREQUENCY:YesNoHow many times do you wake up at night to urinate? NOCTURIA:YesNoDo you ever find that your bed is wet from urine?YesNoDo you completely empty your bladder each time?YesNoDo you strain in order to urinate?YesNoDo you wear pads/liners to protect you from urine leaking?YesNoHow many per day?Are they soaked through?YesNoDo you have accidents or staining on your underwear from Bowel Movements?YesNoDo you have a pressure sensation/heaviness in you vagina area?YesNoHave you noticed a bulge coming out from your vagina area?YesNoFluid Intake: How many cups per day:CoffeePlease enter a number greater than or equal to 0.TeaPlease enter a number greater than or equal to 0.WaterPlease enter a number greater than or equal to 0.MilkPlease enter a number greater than or equal to 0.JuicePlease enter a number greater than or equal to 0.PopPlease enter a number greater than or equal to 0.Other Drinks:Please enter a number greater than or equal to 0.Social HistoryOccupationRelationship:SingleCommon-lawMarriedWidowOtherIs your relationship with your husband/partner safe, and supportive?YesNoLive alone?YesNoWould you like to receive information on Meridia Medical events and blog tips?YesNoCAPTCHAWhen complete please submit.