University of North Carolina Wilmington ♦ Abrons Student Health Center
AHME History Form (Age <40)
Date_____/_____/ 20____
Place Label Here
Chart #_________
Medical History:
Condition
Self
Y
N
Family
Y
N
1-Heart attack/disease
2-Stroke
3-Blood clots
4-Migraines/headaches
5-Depression/anxiety
6-Acne
7-Thyroid disease
8-Breast lumps/disease
9-High blood pressure
10-Lupus
11-Liver/gallbladder disease
12-Anemia
13-Cancer
Condition
Self
Y
N
Family
Y
N
14-Eating disorders
15-Suicide attempts
16-Alcohol abuse
17-Other Drug abuse
18-Herpes
19-Chlamydia
20-Gonorrhea
21-Hepatitis
22-Trichomonas
23-HIV/AIDS
24-Syphilis
25-HPV/Warts
26-Other
Please explain any positive responses:
If you have headaches, are they ever associated with visual changes, blurring, or other unusual sensations? Y / N
Have you been diagnosed with any medical conditions or been hospitalized? Y / N
Do you take any medicines? Y / N
Do you take any over-the-counter (OTC) medicines or supplements? Y/N
Do you have any drug allergies? Y / N_____________________ Ever had your cholesterol checked? Y / N
GYN History:
Date of last menstrual period:
Do you check your breasts regularly? Y / N
Do you have any problems with your periods? Y / N
If yes, explain
Ever had intercourse? Y / N
When was the last time?
Type of sex? Vaginal / Oral / Anal
Partners? Men / Women / Both
How many partners have you had in the past 6 months?_________
Have you had the gardasil vaccine? Y/ N
If yes, how many doses? 1 / 2 / 3
Lifetime?__________
Interested / Not interested
Did you complete it before your first sexual experience? Y / N
Ever been pregnant? Y / N / Possible If yes, when? ____________Outcome?
Ever had a pap smear? Y / N
Date: _______________
Ever had an abnormal pap smear? Y / N
Details:
Are you having any unusual vaginal discharge? Y / N
SHC 03/12
Results:
Any pain and/or bleeding with intercourse? Y / N
Social History:
Alcohol: _____ drinks/week
Age started_____
Tobacco: _____cigs/day
Age started _____
Recreational drug use: _________________
Age started: _____
Do you exercise? Y / N
________hours
How is your diet?__________________
Do you restrict your food intake in any way?
Sexual assault/abuse: Past/ Present / No
Physical abuse: Past/ Present / No
___________days/week
Childhood physical or sexual abuse: Y / N
If yes to any of the above 3 questions, do you want to discuss? Y / N
Contraceptive History:
Method
Now
Past
Problems
Condoms
Birth control pills
Nuva Ring
Depo Provera
IUD
Implanon
Withdrawal (pulling out)
Other
What method of birth control would you like to use?
Review of Systems: Circle any that have been present for more than 4 weeks.
General:
Unexplained weight loss or gain, fatigue, fevers, night sweats
Skin:
Changes in existing moles, unusual looking new moles, poorly healing wounds, rashes
Head/Neck:
Blurred vision, double vision, sores in mouth
Cardiac:
Chest pain, racing or irregular heart beat
Pulmonary:
Cough, wheeze, shortness of breath with activity
GI:
diarrhea, constipation, change in bowel habits, blood in stool, black stools, abdominal pain
GU:
pain with urination, blood in urine, frequent UTIs, vaginal discharge, pain with sex, genital bumps
Breasts:
Pain in breast, lumps, nipple discharge
M/S:
Unexplained muscle or joint pain, swelling, limitations in normal activities
Neuro:
frequent headaches, fainting, blackouts, seizures weakness, numbness, tingling
Psych:
depression, anxiety, mood swings, feeling persistently down in the dumps, thought of suicide
Student Signature____________________________
Date__________________
____Provider Reviewed
SHC 03/12