Welcome to VitalLink
Please fill out the following information to complete your medical intake:
First Name*:
Last Name*:
Birthdate*:
Today's Date*:
Appointment Date*:
Height*:
Weight*:
Email*:
Physician*:
Ben Moyette, MD
Celeste Moyette, DO
Michael Sherrod, MD
Medical History:
Vaginal Bleeding
Pain During Sex
Abnormal Vaginal Discharge
Pelvic Pain
Abnormal Uterine Bleeding
Missed Period
Painful Period
Ovarian Cysts
Polycystic Ovary Syndrome
Endometriosis
Fibroids
Vaginal Itching
Vaginal Odor
Vulvar Itching
Vulvar Pain
Yeast Infection
Bacterial Vaginosis
Sexually Transmitted Infection
Cervical Cancer
Ovarian Cancer
What Brings You In Today:
Abnormal vaginal bleeding
Vaginal itching and burning
Pain during sex
Pelvic pain
Urinary incontinence
Vaginal discharge
Missed periods
Breast changes
Painful periods
Infertility
Menopausal symptoms
Ovarian cysts
Uterine fibroids
Endometriosis
Cervical cancer
Ovarian cancer
Vulvar cancer
Uterine cancer
Sexually transmitted infections
Pregnancy-related complications
Chest pain
Shortness of breath
High blood pressure
Type 2 diabetes
Type 1 diabetes
Obesity
Thyroid problems
Gastrointestinal problems
Headaches
Joint pain
Back pain
Depression
Anxiety
Insomnia
Chronic fatigue
Cancer
Kidney disease
Liver disease
Autoimmune diseases
Infectious diseases
Medications:
OBGYN-Specific Information
Last Menstrual Period (LMP):
Pregnancy Status:
Pregnant
Not Pregnant
Due Date (if pregnant):
Pregnancy Complications (if any):
Emergency Contact
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