Medical History Date___________ Name _____________________ Age_______ Date of birth ____________ Primary care doctor name and address_____________________________________________ Medical History: Have you ever had any of the following: ___Genetic conditions or birth defects ___Alcoholism or drug dependency ___Heart Disease or heart murmur ___Frequent urinary tract infections ___Chest pain ___Kidney infections ___Shortness of breath ___Kidney stone ___High blood pressure ___Lupus or fibromyalgia ___Diabetes ___Arthritis ___High cholesterol ___Spine, hip or knee problems ___Frequent headaches/migraines ___Breast disease ___Gastrointestinal problems ___Osteoporosis ___Constipation ___Unintentional, rapid weight loss or gain ___Rectal bleeding ___Thyroid problems ___Gallbladder problems ___Skin rashes ___Liver problems ___Epilepsy/convulsions ___Anemia ___Tuberculosis ___Asthma ___Blood transfusion ___Psychiatric care ___Problems with anesthetics ___Depression or anxiety Cancer: ___Uterus ___Breast ___Cervix ___Colon ___Ovary Other: __________________ Medications (including over the counter and supplements): Name Dose How often Drug Allergies: Name Reaction Purpose Obstetric and Gynecologic history: Pregnancy History (include miscarriage, ectopic pregnancy, abortion, and pregnancies): Year, Weeks/Months (how Gender/Weight Complications? Vaginal or C-section far along were you?) First day of last menstrual period_______________ Age first period began________________ Do you have bleeding between periods? ______Yes _________No How many days between periods_______________ Regular cycles? _________________ How many days do your periods last?_______ Number of pads/tampons on your heaviest day________ Do you have painful cramps that stop you from taking care of daily responsibilities? ___Yes ___No Do you have: ___Recurrent vaginal infections (yeast or BV) History of STDs (Gonorrhea, Chlamydia, Herpes, genital warts, HIV, etc): ____________ ___Pain with intercourse Are you sexually active? ____Yes ____No If not, since when? ______ How long have you been with your current sexual partner? _________ Is (Are) your partner(s) _____Male ____Female _____Both Age at first intercourse ______ Number of sexual partners in your life _______ Do you have (or have a history of): ___Fibroids ___Breast cyst/mass/pain ___Endometriosis ___Blood in your urine ___Infection of pelvic organs ___Leakage of urine or frequent urination ___Pelvic pain ___Hot flashes or problems sleeping ___Nipple discharge Birth control method (pills, condoms, IUD, natural family planning, etc): ________________________ Other birth control methods you have used in the past: _________________________ Are you satisfied with your birth control? __________________________ Surgical History and Hospitalization: Date Length of Illness or Operation Stay Anesthesia Complications Social History: Are you: ___Single ___Married ___Divorced ___Widowed Do you: Smoke Cigarettes? ____ Number per day ____ Did you smoke in the past?_____ Do you: Drink alcohol? _____ Drinks per week _____ Do you: Drink coffee? _______ Drinks per week ________ Other recreational drugs? ________________________ With whom do you live?____________________________ Do you exercise? How many times per week, and what do you do? _____________________________ ___________________________________________________________________________________ Family history: Please list age at which the family member was diagnosed: Heart problems_______________________ Fibroids_____________________________ Stroke or paralysis_____________________ Infertility____________________________ Blood clots___________________________ Polycystic ovarian syndrome____________ Jaundice or Liver problems______________ Cancer: Kidney disease________________________ Breast cancer________________________ Diabetes____________________________ Uterine cancer________________________ High blood pressure___________________ Ovarian cancer_______________________ Genetic problems, birth defects__________ Cervical cancer_______________________ Thyroid problems_____________________ Colon cancer_________________________ Alcoholism or drug dependency__________ Other:_________________________ Bleeding problems____________________ Healthcare Maintenance (please write approximate date): Last pap (over age 21): ______________________ History of abnormal paps: ___________________ Last mammogram (over age 40):_______________ Last bone scan (DEXA) (over age 65): ___________ Last colonoscopy (over age 50): ________________ Last Tetanus-Diptheria booster vaccine:___________ Have you had your: _____________HPV vaccine (under age 26) _____________Pneumococcal vaccine (over age 65) _____________Shingles (Zooster) vaccine (over age 60) Pharmacy you use: ____________________________________