Timothy N. Gorski,  M.D., F.A.C.O.G.
1001 North Waldrop, Suite 815
Arlington, Texas  76120
(817) 792-2000

Name: _____________________________________________________________ Date: _____________________________

Patient Visit Questionnaire

What is the reason for you visit today? ___________________________________________________________________
	
During your menstrual cycles do you have
•	Irregular Bleeding?
•	Heavy Prolonged Bleeding?
•	Cramps/Pain with Periods?

Do you have
•	Pelvic/Abdominal Pain?
•	Abnormal Vaginal Discharge?
•	Urinary Problems (pain, leakage, etc.?)
•	Bowel Problems?
•	Breast Pains, Lumps, or Discharges?
•	Physical/Mental/Sexual Abuse?

Since your last visit, have you had any
•	Medical Problems?
•	Surgeries? 
•	Hospitalizations?
•	Sexual Problems?
•	Dental Problems?
•	Changes in a Family Members Health?

Do you plan to become pregnant within the next 12 months? __________

Please list your use of

Prescription Medications: ___________________________________________________________________

Tobacco: _________________________________________________________________________________

Alcohol: _________________________________________________________________________________

Caffeine (coffee, tea, cola, etc.) _______________________________________________________________

Vitamins/Supplements: _____________________________________________________________________

How do you get Calcium in your diet? ________________________________________________________

Phone # where you can be reached during the day: ______________________________________________