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Marital Status:
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REFERRED BY:
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WHY HAVE YOU COME TO THE OFFICE TODAY?
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PLEASE DESCRIBE YOUR PROBLEM, INCLUDING WHERE IT IS AND HOW LONG IT HAS LASTED.
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Health Information
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Date of Last Menstrual Period (FIRST DAY- mmddyyy)
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Have you been diagnosed with any gynecological problems? If so, please list them.
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Age of first menstrual period.
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WHEN WAS YOUR LAST PAP TEST? ?(MM/DD/YYYY)
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HAVE YOU EVER HAD AN ABNORMAL PAP TEST?
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WHAT WAS THE RESULT?
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How many pregnancies have you had?
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How many live births have you had?
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How many misscarriages have you had?
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How many pregnancy terminations have you had?
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Any pregnancy complications?
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Have you ever had any difficulty conceiving?
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Have you ever had pelvic infections?
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If YES, what type and when?
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OBSTETRIC HISTORY
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PREGNANCIES
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PREM ATURE BIRTHS (<37 WEEKS)
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ABORTIONS
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LIVE BIRTHS
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MISCARRIAGES
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LIVING CHlLDREN
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CURRENT MEDICATIONS
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(Including hormones, vitamins, herbs, nonprescription medications)
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DRUG NAME (1)
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DRUG NAME (2)
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DRUG NAME (3)
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DRUG NAME (4)
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DRUG NAME (5)
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DRUG NAME (6)
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DRUG NAME:
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DOSAGE
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DRUG NAME:
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DOSAGE
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DRUG NAME:
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DOSAGE
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DRUG NAME:
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DOSAGE
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DRUG NAME:
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DOSAGE
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DRUG NAME:
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DRUG NAME:
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FAMILY HISTORY
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DIABETES
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WHICH RELATIVE(S) AFFECTED
• • •
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STROKE
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WHICH RELATIVE(S) AFFECTED
• • •
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HEART DISEASE
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WHICH RELATIVE(S) AFFECTED
• • •
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BLOOD CLOTS IN LUNGS OR LEGS
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WHICH RELATIVE(S) AFFECTED
• • •
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HIGH BLOOD PRESSURE
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WHICH RELATIVE(S) AFFECTED
• • •
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BREAST CANCER
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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COLON CANCER
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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OVARIAN CANCER
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WHICH RELATIVE(S) AFFECTED
• • •
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AGE OF ONSET
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UTERINE CANCER
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WHICH RELATIVE(S) AFFECTED
• • •
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OTHER ILLNESS:
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WHICH RELATIVE(S) AFFECTED
• • •
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SOCIAL HISTORY
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EVER SMOKED?
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CURRENTLY SMOKING _____ PACKS PER DAY
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ALCOHOL
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TYPE OF DRINK
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DRINKS PER DAY
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DRINKS PER WEEK
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DRUG USE
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REGULAR EXERCISE
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HAVE YOU BEEN ABUSED, THREATENED, OR HURT BY ANYONE?
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DO YOU HAVE AN ADVANCED DIRECTIVE (LIVING WILL)?
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PERSONAL PAST HISTORY OF ILLNESSES
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ASTHMA
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IF YES, PLEASE INDICATE THE DATE
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PNEUMONIA/LUNG DISEASE
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IF YES, PLEASE INDICATE THE DATE
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KIDNEY INFECTIONS/STONES
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IF YES, PLEASE INDICATE THE DATE
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TUBERCULOSIS
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IF YES, PLEASE INDICATE THE DATE
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FIBROIDS
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IF YES, PLEASE INDICATE THE DATE
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SEXUALLY TRANSMITTED DISEASE/CHLAMYDIA
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IF YES, PLEASE INDICATE THE DATE
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HIV/AIDS
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IF YES, PLEASE INDICATE THE DATE
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HEART ATTACK/DISEASE
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IF YES, PLEASE INDICATE THE DATE
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DIABETES
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IF YES, PLEASE INDICATE THE DATE
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HIGH BLOOD PRESSURE
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IF YES, PLEASE INDICATE THE DATE
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STROKE
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IF YES, PLEASE INDICATE THE DATE
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BLOOD CLOTS IN LUNGS OR LEGS
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IF YES, PLEASE INDICATE THE DATE
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EATING DISORDERS
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IF YES, PLEASE INDICATE THE DATE
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AUTOIMMUNE DISEASE (LUPUS)
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IF YES, PLEASE INDICATE THE DATE
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CANCER
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IF YES, PLEASE INDICATE THE DATE
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DEPRESSION/ANXIETY
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IF YES, PLEASE INDICATE THE DATE
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ANEMIA
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IF YES, PLEASE INDICATE THE DATE
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BLOOD TRANSFUSIONS
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IF YES, PLEASE INDICATE THE DATE
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HEPATITIS/LIVER DISEASE
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IF YES, PLEASE INDICATE THE DATE
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BLEEDING DISORDER
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IF YES, PLEASE INDICATE THE DATE
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OTHER
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OPERATIONS/HOSPITALIZATIONS
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REASON
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DATE
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REASON
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DATE
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REASON
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DATE
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REASON
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DATE
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REASON
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DATE
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REASON
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DATE
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INVOLUNTARY/UNINTENDED URINE LOSS
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COMMENT
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URINE LOSS WHEN COUGHING OR LIFTING
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COMMENT
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ABNORMAL BLEEDING
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COMMENT
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PAINFUL PERIODS
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COMMENT
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PREMENSTRUAL SYNDROME (PMS)
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COMMENT
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PAINFUL INTERCOURSE
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COMMENT
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ABNORMAL VAGINAL DISCHARGE
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COMMENT
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MUSCLE WEAKNESS
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COMMENT
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MUSCLE OR JOINT PAIN
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COMMENT
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MOLES (GROWTH OR CHANGES)
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COMMENT
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PAIN IN BREAST
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COMMENT
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NIPPLE DISCHARGE
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COMMENT
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LUMPS
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COMMENT
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DIZZINESS
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COMMENT
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SEIZURES
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COMMENT
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NUMBNESS
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COMMENT
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TROUBLE WALKING
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COMMENT
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MEMORY PROBLEMS
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COMMENT
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FREQUENT HEADACHES
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COMMENT
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DEPRESSION OR FREQUENT CRYING
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COMMENT
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ANXIETY
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COMMENT
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SEXUAL HEALTH CONCERNS
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COMMENT
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HAIR LOSS
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COMMENT
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HEAT/COLD INTOLERANCE
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COMMENT
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ABNORMAL THIRST
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COMMENT
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HOT FLASHES
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COMMENT
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FREQUENT BRUISES
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COMMENT
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IF ANY, PLEASE LIST ALLERGY AND TYPE OF REACTION
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LATEX ALLERGY
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COMMENT
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OTHER ALLERGIES
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COMMENT
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MEDICATION ALLERGIES
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FORM COMPLETED BY:
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