Student Affairs
Student Health Services
WOMEN’S HEALTH CLINIC: HEALTH HISTORY FORM
NAME_______________________________ SUNY ID_____________DOB___/___/___AGE_____
Last
First
M.I.
Mo. Day Year
GYNECOLOGICAL/MENSTRUAL/PREGNANCY HISTORY
Age of first menses: _____ Does your menses come monthly? _____ Are they Heavy? _____
How many pads/tampons do you use on your heaviest day? _____ Are they painful? _____
When was your last GYN exam? _____ Last STI screen? _____ Last Pap Smear? _____
Are you currently or ever been sexually active? _____
Have you ever been diagnosed with a sexually transmitted infection? _________
If yes, explain: _______________________________________________________________________
Have you ever had an abnormal pap smear? _______
If yes, explain: ____________________________________________________________________
Have you ever been pregnant? ____ # live births ___ #abortions/miscarriages ____ Stillbirths____
Have you ever had or have current GYN problems? _____ Explain:_____________________________
____________________________________________________________________________________
Did you have the Gardasil vaccines? _____. If yes,When:______________________________________
CONTRACEPTIVE HISTORY
Do you use condoms to protect from STI’s and/or to prevent pregnancy? _____
Are you using any other birth control method now? ____ If yes, what: ___________________________
What methods have you used in the past? __________________________________________________
Reason for changing methods: ___________________________________________________________
MEDICAL HISTORY
YES
Have you had any of the following? (Check only ones you have or had)
YES
YES
_____ Migraine headaches
_____Breast disease
_____ Stroke
_____ Epilepsy
_____ Severe depression
_____Thyroid problems
_____ Liver disease/Hepatitis
_____ Heart disease/Murmur
_____ High blood pressure
_____ Blood clots/blood disorders _____ Stomach/bowel problems
_____Gall bladder problem
_____Asthma/breathing problems _____ Kidney/Bladder problems
_____ Cancer
COMMENTS: ______________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
SURGICAL HISTORY (record surgeries including dates)
_____________________________________________________________________
_____________________________________________________________________
FAMILY HISTORY (PARENTS AND SIBLINGS)
Unsure NO YES
Diabetes
____
___ ___
Stroke
____
___ ___
Cancer
____
___ ___
Heart Attack ____ ___ ___
WHO
__________ High Blood Pressure
__________ Breast Disease
__________ Osteoporosis
__________
Hereditary Disease
Unsure NO YES
____
___ ___
____
___ ___
____
___ ___
____
___ ___
WHO
_________
_________
_________
_________
_________________________________________Reviewed_____________________________
STUDENTS SIGNATURE
DATE
D. Walker NP/ D. Hirt NP DATE
Revised 8/2015