Name: _______________________________ Birthdate: ____________ Date: ____________
Reason for Visit: _______________________________________________________________
PLEASE READ ALL QUESTIONS AND ANSWER TO BEST OF YOUR KNOWLEDGE!!!
Allergies:
Medications
Environmental
Food
None 
None Latex 
None 
Medications/Supplements (Regular or Occasional Use) : Please indicate name and dose
None 
Medical/Surgical History:
Current
Past
Condition/Disease
Headaches, migraines, auras
Eye problems, hearing loss
Seizures/neurologic problems
Strokes
Depression, anxiety, mental
disorders
Thyroid disease
Heart disease/heart attacks
High blood pressure
Mitral valve prolapse/ heart
infection
Blood clots in legs or lungs
Excessive bleeding or bruising
Anemia
Blood transfusions
Current
Past Conditions/Disease
High cholesterol, lipids
Asthma, lung disease, tuberculosis
Hepatitis, liver, gallbladder disease
Diabetes
Ulcers, heartburn, stomach problems
Bladder or kidney infections
Kidney Stones
Muscle, bone, joint problems
Breast problems, lumps, cancer
Gynecologic problems
Abnormal pap smears
Surgeries, Accidents, Hospitalizations
Other
Screening History:
Last Pap: _________(date)-normal or ______________________ High Risk HPV testing? ______________
Last Mammogram: __________ (date)-normal or ______________________________
Prior Cholesterol/Lipid Screening: _________ (date)-normal or _____________________________
Last Bone Density Scan: _________ (date)-normal or ______________________
Last Colonoscopy/Sigmoidoscopy: _________ (date)-normal or ___________________________
Gynecologic History:
Menstrual: LMP (1st day) __________ Frequency (between 1st days) - ____ days
Duration - ____days
Regular  Irregular Flow - light moderate heavy  varies 
Bleeding between periods? No  Yes 
Age period started - ___ years
Pregnancy: Total Number Pregnancies - _____ Births - _____ Preterm - _____ Miscarriage - _____
Abortion - _____ Ectopic - _____
Vaginal - _____ C-Section - _____ Living Children-_____
Sexual: Orientation – Opposite sex  Same sex  Both Transgender – No 
Yes 
Current Partner(s) - No 
Yes 
Time with Partner(s) - ___ weeks months years
Contraception: Current _____________________ Desired _______________________ None
Infections (Circle): Gonorrhea
Chlamydia
Herpes (self/partner) Venereal Warts Hepatitis
Syphilis
HIV
Trich
BV
Yeast
Pelvic Inflammatory Disease MRSA (past 1 year)
Trauma History
Have you ever been sexually abused, raped or molested? No Yes 
Have you ever been in a psychologically or physically abusive relationship? No Yes 
Do you feel safe in your current relationship? Yes  No  Not currently in a relationship 
Family History
Mother
Father
Sister
Brother
MatGM
MatGF
Maternal
Aunts/Uncles
PatGM
PatGF
Paternal
Aunts/Uncles
Child
Hypertension
Blood Clot/Stroke
Heart attack
High cholesterol
Diabetes
Breast cancer
Ovarian cancer
Colon cancer
Osteoporosis
Other
Social/Lifestyle History:
Marital Status: Single Married Separated  Divorce Widowed Domestic Partner 
Tobacco History: Smoker - Never  Former  Quit _______ (date) Current ___Cigs/day x ___yrs Chews 
Alcohol: Never 
In past or ___drinks per day  week  month  year 
Recreational Drugs: Never  In past Current Substances:
Exercise: No or
____ times per week for ____ minutes
Light Moderate Heavy
Current Symptoms:
ROS
General
Skin
Please circle all CURRENT complaints
appetite loss
chills
fatigue
weight gain/obesity
weight loss
nail changes dryness hair growth
feels poorly
fever
other _____________
hair loss itching lesions
rash
other ____________
HEENT
vision changes corrective lenses
sore throat
other ____________
Neck
Respiratory
Breast
Cardiovascular
Gastrointestinal
pain
stiffness
swollen glands
other____________
cough difficulties breathing snoring sputum wheezing other ______________
mass pain swelling nipple discharge nipple pain recent change In size skin changes
chest pain edema fainting irregular rate palpitations rapid rate other ______________
abdominal pain bloating diarrhea constipation heartburn nausea rectal bleeding vomiting
other _____________
abnormal vaginal bleeding absence of menses discharge frequent urination incontinence
painful intercourse painful menstruation painful urination pelvic pain urgency
vaginal dryness
vaginal itching
excessive urination at night
other ____________________
Genitourinary
Musculoskeletal
Neurologic
Psychiatric
Endocrine
Blood and Lymph
Other
hearing loss nose
night sweats
bleeds ringing ears
sinus pain
runny nose
back pain joint pain
joint swelling
muscle pain
muscle weakness
other _____________
ADD(attention deficit) dizziness
fainting headaches numbness tingling tremors seizures
other _____________
anxiety depression insomnia memory loss suicidal ideation feels safe @ home frequent crying
appetite change cold intolerance
excessive thirst excessive urination heat intolerance
libido change other ______________
anemia blood clots easy bruising prolonged bleeding swollen nodes
other ______________
other
9/1/14