Patient Intake

The below information 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.

Personal Information

Name*

First Name Last Name

Age*

Birth Date*

Sex*

Male
Female

Address*

Street Address Apartment/Suite # City State / Province / Region ZIP / Postal Code Country

Email*

Home Phone*

Work Phone

Mobile Phone

Please check the telephone # we can use to contact you:*

The number that you prefer we call first

Home
Mobile
Work

Health Card #*

Version Code:*

Which province is your health card from?*

Family Doctor

Referred by

Gynecological History

Are you menopausal*

Yes
No

Since when?

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*

How often are your periods? (In days)*

Are your periods regular?*

Yes
No

How many days do you bleed?

Age of your first period?*

Are your periods painful?

Yes
No

Are your periods heavy?*

Yes
No

Do you bleed between periods?*

Yes
No

Do you have bleeding after intercourse?*

Yes
No

Date of your last PAP smear*

Has your PAP smear ever been abnormal?

Yes
No

Have you had treatment for an abnormal PAP smear?*

Yes
No

What form of contraception do you use now*

Have you used a birth control pill?*

Yes
No

Please let us know the name and when you took it

Name	When

Have you used an IUD (Intra-Uterine Device)?*

Yes
No

Have you ever had a Pelvic Infection (PID)?*

Yes
No

Have 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)?*

Yes
No

Have you had a mammogram?*

Yes
No

When last?

Have you had a bone density test?*

Yes
No

When last?

Do you take any of the below supplements?*

Check all that apply

Calcium
Vitamin D
None

Obstetric History

Have you ever been pregnant?*

Yes
No

Please list ALL pregnancies (Date and outcome):

Date	Outcome: (Miscarriage, Termination, Live Birth, Stillbirth etc	Method: (D&C, Vaginal delivery, Forceps, C-Section)	Sex	Birthweight	Comments

Medical History

Please list ANY medical conditions you have/had: (e.g. Asthma, Diabetes, Thyroid, Hypertension, Depression)*

Type N/A if you've had none

List ALL current medications:

Name and dose please, including Herbal and Natural remedies

Medication Name	Dosage

Allergies to Medications:

If allergic, please list all drug names and the reaction.

Drug Name	Reaction

Are you allergic to Latex?*

Yes
No

Have you ever had a BLOOD Transfusion?*

Yes
No

Have you ever had an operation?*

Yes
No

What was the reason and date of your operation?

Reason	Date

Have you EVER been hospitalized for any reason other than above?*

Yes
No

Please state the reason and date of hospitalization

Reason	Date

Do you smoke?*

Yes
No

How many/day?

Do you drink alcohol regularly?*

Yes
No

How 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/Illness	Relative

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 no*

Yes
No

Sexual History

Many 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?*

Yes
No

Do you have pain with intercourse?*

Yes
No

Is the pain on the outside or deep inside?*

Outside
Deep Inside

Do you have any of the below 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 History

Often 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 exercise

Yes
No

Do you leak urine/have accidents?*

Yes
No

Do you leak urine when coughing, laughing, sneezing, dancing, running etc? STRESS Incont:*

Yes
No

Do you have to run to the toilet urgently when you feel the urge to go? URGENCY:*

Yes
No

Do you sometimes leak before you reach the toilet bowl? URGE Incont:*

Yes
No

Do you just leak at any time, without warning? UNAWARE Incont:*

Yes
No

How often do you urinate during the day? FREQUENCY:*

Yes
No

How many times do you wake up at night to urinate? NOCTURIA:*

Yes
No

Do you ever find that your bed is wet from urine?*

Yes
No

Do you completely empty your bladder each time?*

Yes
No

Do you strain in order to urinate?*

Yes
No

Do you wear pads/liners to protect you from urine leaking?*

Yes
No

How many per day?

Are they soaked through?*

Yes
No

Do you have accidents or staining on your underwear from Bowel Movements?*

Yes
No

Do you have a pressure sensation/heaviness in you vagina area?*

Yes
No

Have you noticed a bulge coming out from your vagina area?*

Yes
No

Fluid Intake: How many cups per day:

Coffee

Tea

Water

Milk

Juice

Pop

Other Drinks:

Social History

Occupation

Relationship:*

Is your relationship with your husband/partner safe, and supportive?

Yes
No

Live alone?

Yes
No

Would you like to receive information on Meridia Medical events and blog tips?

Yes
No

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