|
Gynecologic History
|
|
|
Date of last Physical Exam
|
Date of Positive Pregnancy Test
|
|
Age of First Period
|
Frequency of Menses
|
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Date of Last Menstrual Period
|
|
|
Menstrual Problems
• • •
|
Menstrual Freewrite
|
|
Last Pap
|
|
|
Previous Abnormal Pap Tests
• • •
|
Pap Freewrite
|
|
Abnormal Bleeding
• • •
|
Abn Bleeding Freewrite
|
|
Method of Birth Control
• • •
|
|
|
Birth Control Problems
• • •
|
Birth Control Freewrite
|
|
Sterilization
• • •
|
|
|
History of Breast Problems/Disease?
• • •
|
Breast Problems Freewrite
|
|
History of Sexually Transmitted Disease or bacterial infections?
• • •
|
Infections Freewrite
|
|
History of Endometriosis?
• • •
|
What Treatments
|
|
History of Infertility?
|
What tests and/or treatments
|
|
History of Female Cancer
• • •
|
Cancer Freewrite
|
|
History of Alcohol Abuse?
• • •
|
If yes, details
|
|
History of Domestic Violence?
|
Relationship to you
|
|
DES Exposure
|
|
|
|
|
|
Obstetric History
|
|
|
Year
|
City/State
/
|
|
Length of Pregnancy
|
Hours in Labor
|
|
Complications of Pregnancy/Labor
|
Type of Delivery
• • •
|
|
Sex M/F
• • •
|
Birth Weight(s)
• • •
|
|
|
|
|
Year
|
City/State
/
|
|
Length of Pregnancy
|
Hours in Labor
|
|
Complications of Pregnancy/Labor
|
Type of Delivery
• • •
|
|
Sex M/F
• • •
|
Birth Weight(s)
• • •
|
|
|
|
|
Year
|
City/State
/
|
|
Length of Pregnancy
|
Hours in Labor
|
|
Complications of Pregnancy/Labor
|
Type of Delivery
• • •
|
|
Sex M/F
• • •
|
Birth Weight(s)
• • •
|
|
|
|
|
Year
|
City/State
/
|
|
Length of Pregnancy
|
Hours in Labor
|
|
Complications of Pregnancy/Labor
|
Type of Delivery
• • •
|
|
Sex M/F
• • •
|
Birth Weight(s)
• • •
|
|
|
|
|
Year
|
City/State
/
|
|
Length of Pregnancy
|
Hours in Labor
|
|
Complications of Pregnancy/Labor
|
Type of Delivery
• • •
|
|
Sex M/F
• • •
|
Birth Weight(s)
• • •
|
|
|
|
|
Year
|
City/State
/
|
|
Complications of Pregnancy/Labor
|
Hours in Labor
|
|
Sex M/F
• • •
|
Type of Delivery
• • •
|
|
|
|
|
Year
|
City/State
/
|
|
Length of Pregnancy
|
Hours in Labor
|
|
Complications of Pregnancy/Labor
|
Type of Delivery
• • •
|
|
Sex M/F
• • •
|
Birth Weight(s)
• • •
|
|
|
|
|
Year
|
City/State
/
|
|
Length of Pregnancy
|
Hours in Labor
|
|
Complications of Pregnancy/Labor
|
Type of Delivery
• • •
|
|
Sex M/F
• • •
|
Birth Weight(s)
• • •
|
|
|
|
|
Surgical History
|
|
|
Year
|
City/State
/
|
|
Type of Surgery
• • •
|
Type of Surgery Freewrite
|
|
Complications
|
|
|
|
|
|
Year
|
City/State
/
|
|
Type of Surgery
• • •
|
Type of Surgery Freewrite
|
|
Complications
|
|
|
|
|
|
Year
|
City/State
/
|
|
Type of Surgery
• • •
|
Type of Surgery Freewrite
|
|
Complications
|
|
|
|
|
|
Year
|
City/State
/
|
|
Type of Surgery
• • •
|
Type of Surgery Freewrite
|
|
Complications
|
|
|
|
|
|
Year
|
City/State
/
|
|
Type of Surgery
• • •
|
Type of Surgery Freewrite
|
|
Complications
|
|
|
|
|
|
Year
|
City/State
/
|
|
Type of Surgery
• • •
|
Type of Surgery Freewrite
|
|
Complications
|
|
|
|
|
|
Year
|
City/State
/
|
|
Type of Surgery
• • •
|
Type of Surgery Freewrite
|
|
Complications
|
|
|
|
|
|
Year
|
City/State
/
|
|
Type of Surgery
• • •
|
Type of Surgery Freewrite
|
|
Complications
|
|
|
|
|
|
Health Maintenance
|
|
|
Cholesterol Screening
|
Date
|
|
Results
|
|
|
Mammogram
|
Date
|
|
Results
|
|
|
Colonoscopy
|
Date
|
|
Results
|
|
|
Bone Density Scan
|
Date
|
|
Results
|
|
|
Patient's diet
|
Caffeine
|
|
Tobacco
• • •
|
Quite Date
|
|
Alcohol
|
Drinks per Week
|
|
Excercise
|
Times Per Week
|
|
Vitamins and /or Calcium Supplements
|
|
|
Recreational Drug Use
• • •
|
Drugs
• • •
|
|
Have you used or shared needles?
|
|
|
|
|
|
Current Medications
|
|
|
Present Medications
|
Dosage and Frequency
|
|
Prescribing Physician
|
|
|
Present Medications
|
Dosage and Frequency
|
|
Prescribing Physician
|
|
|
Present Medications
|
Dosage and Frequency
|
|
Prescribing Physician
|
|
|
Present Medications
|
Dosage and Frequency
|
|
Prescribing Physician
|
|
|
Present Medications
|
Dosage and Frequency
|
|
Prescribing Physician
|
|
|
Present Medications
|
Dosage and Frequency
|
|
Prescribing Physician
|
|
|
|
|
|
Medical Allergies
|
|
|
Medical Allergies
|
|
|
Medication
|
Reactions
• • •
|
|
Medication
|
Reactions
• • •
|
|
Medication
|
Reactions
• • •
|
|
Medication
|
Reactions
• • •
|
|
Medication
|
Reactions
• • •
|
|
|
|
|
Medical History
|
|
|
Are you adopted?
|
|
|
Cardiovascular Disease (Heart)
• • •
|
Comments
|
|
Pulmonary Disease
• • •
|
Comments
|
|
Endocrine Disease
• • •
|
Comments
|
|
Gastrointestinal Disease
• • •
|
Comments
|
|
Bladder/Kidney Infections
• • •
|
Comments
|
|
Neurological Problems
• • •
|
Comments
|
|
Hematologic (Blood) Disease
• • •
|
Comments
|
|
Musculoskeletal Disorders
• • •
|
Comments
|
|
Psychiatric/Emotional Problems
• • •
|
Comments
|
|
Genetic (inherited) or Congenital Diseases
• • •
|
Comments
|
|
Other Autoimmune Disease
• • •
|
Comments
|
|
History of Cancer Other than Female
• • •
|
Comments
|
|
|
|
|
Family History
|
|
|
Father's Medical History
|
|
|
Cardiovascular Disease (Heart)
• • •
|
Pulmonary Disease
• • •
|
|
Endocrine Disease
• • •
|
Gastrointestinal Disease
• • •
|
|
Bladder/Kidney Infections
• • •
|
Neurological Problems
• • •
|
|
Hematologic (Blood) Disease
• • •
|
Musculoskeletal Disorders
• • •
|
|
Psychiatric/Emotional Problems
• • •
|
Genetic (inherited) or Congenital Diseases
• • •
|
|
Other Autoimmune Disease
• • •
|
History of Cancer
• • •
|
|
Any others not listed above
|
|
|
|
|
|
Mother's Medical History
|
|
|
Cardiovascular Disease (Heart)
• • •
|
Pulmonary Disease
• • •
|
|
Endocrine Disease
• • •
|
Gastrointestinal Disease
• • •
|
|
Bladder/Kidney Infections
• • •
|
Neurological Problems
• • •
|
|
Hematologic (Blood) Disease
• • •
|
Musculoskeletal Disorders
• • •
|
|
Psychiatric/Emotional Problems
• • •
|
Genetic (inherited) or Congenital Diseases
• • •
|
|
Other Autoimmune Disease
• • •
|
History of Cancer
• • •
|
|
Any others not listed above
|
|
|
|
|
|
Sibling's Medical History
|
|
|
Cardiovascular Disease (Heart)
• • •
|
Pulmonary Disease
• • •
|
|
Endocrine Disease
• • •
|
Gastrointestinal Disease
• • •
|
|
Bladder/Kidney Infections
• • •
|
Neurological Problems
• • •
|
|
Hematologic (Blood) Disease
• • •
|
Musculoskeletal Disorders
• • •
|
|
Psychiatric/Emotional Problems
• • •
|
Genetic (inherited) or Congenital Diseases
• • •
|
|
Other Autoimmune Disease
• • •
|
History of Cancer
• • •
|
|
Any others not listed above
|
|
|
|
|
|
Maternal Grandparent's Medical History
|
|
|
Cardiovascular Disease (Heart)
• • •
|
Pulmonary Disease
• • •
|
|
Endocrine Disease
• • •
|
Gastrointestinal Disease
• • •
|
|
Bladder/Kidney Infections
• • •
|
Neurological Problems
• • •
|
|
Hematologic (Blood) Disease
• • •
|
Musculoskeletal Disorders
• • •
|
|
Psychiatric/Emotional Problems
• • •
|
Genetic (inherited) or Congenital Diseases
• • •
|
|
Other Autoimmune Disease
• • •
|
History of Cancer
• • •
|
|
Any others not listed above
|
|
|
|
|
|
Paternal Grandparent's Medical History
|
|
|
Cardiovascular Disease (Heart)
• • •
|
Pulmonary Disease
• • •
|
|
Endocrine Disease
• • •
|
Gastrointestinal Disease
• • •
|
|
Bladder/Kidney Infections
• • •
|
Neurological Problems
• • •
|
|
Hematologic (Blood) Disease
• • •
|
Musculoskeletal Disorders
• • •
|
|
Psychiatric/Emotional Problems
• • •
|
Genetic (inherited) or Congenital Diseases
• • •
|
|
Other Autoimmune Disease
• • •
|
History of Cancer
• • •
|
|
Any others not listed above
|
|
|
Children's Medical History
|
|
|
Cardiovascular Disease (Heart)
• • •
|
Pulmonary Disease
• • •
|
|
Endocrine Disease
• • •
|
Gastrointestinal Disease
• • •
|
|
Bladder/Kidney Infections
• • •
|
Neurological Problems
• • •
|
|
Hematologic (Blood) Disease
• • •
|
Musculoskeletal Disorders
• • •
|
|
Psychiatric/Emotional Problems
• • •
|
Genetic (inherited) or Congenital Diseases
• • •
|
|
Other Autoimmune Disease
• • •
|
History of Cancer
• • •
|
|
Any others not listed above
|
|
|
Other Family Member's Medical History
• • •
|
|
|
Cardiovascular Disease (Heart)
• • •
|
Pulmonary Disease
• • •
|
|
Endocrine Disease
• • •
|
Gastrointestinal Disease
• • •
|
|
Bladder/Kidney Infections
• • •
|
Neurological Problems
• • •
|
|
Hematologic (Blood) Disease
• • •
|
Musculoskeletal Disorders
• • •
|
|
Psychiatric/Emotional Problems
• • •
|
Genetic (inherited) or Congenital Diseases
• • •
|
|
Other Autoimmune Disease
• • •
|
History of Cancer
• • •
|
|
Any others not listed above
|
|
|
Social History
|
|
|
Marital Status
• • •
|
Living Arrangements
• • •
|
|
Occupation
|
|
