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: ____________________________________