Center for Colposcopy
Mark Spitzer, MD P.C. FACOG
Gynecology, Colposcopy,
Treatment of Vulvovaginal Diseases
1991 Marcus Avenue, Suite M215
Lake Success, NY 11042
PATIENT HISTORY
Name: _________________________________________ Date of Birth: _____________Age:________ Date: _______________
Who referred you? _______________________________________________________
Last normal period: _________________________________ Marital Status: S
M
D
W
Years Married: _________
Reason for visit today: _______________________________________________________________________________________
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Gynecological history
Please circle if you have had any history of, or are currently experiencing any of the following: Describe all circled items.
Gynecologic cancer _________________________________
fibroids __________________________________________
Breast discharge _____________________________________
Abnormal vaginal discharge _________________________
Abnormal/irregular periods _____________________________
vaginal bleeding/spotting between periods ______________
Breast biopsy/cyst aspiration _____________________________
pain during or after intercourse _______________________
Urinary tract infections ______________________________
ovarian cysts _________________________________
Urinary problems (ie frequency, urgency, difficulty, leaking)_________________________________________________________
Pelvic pain/pelvic inflammatory disease (PID) infections of tubes, ovaries, uterus)________________________________________
Vaginal infections (ie, yeast, trichomonas, bacterial Vaginosis)_______________________________________________________
Pregnancy history:
# Pregnancies ____ # deliveries _____ # vaginal ______ # C/section _____ # abortions ____# miscarriages: ____ # ectopics: ____
Menstrual History:
Age of first period: ____ # of days between cycles: ____ duration of period: ______
If you no longer get your period, at what age did you stop: ______
Cramps with periods: Yes
No
What do you use to relieve the cramps? _________________
Menopause
If you no longer get your period, do you have any symptoms? Yes No If yes, specify: _______________________________
Do you take or have you ever taken Hormone Replacement Therapy (HRT)? Yes
No If yes, what do you use? _____________
Sexual history:
Sexually active? Yes
No
If no, date of last sexual contact: _______ How long with current partner? ________
Age when you first became sexually active: ________ Total # of partners: __________ More than one current partner? ________
Contraceptive history:
Current birth control method: _________________________________ Are you requesting birth control method today? Yes
No
Sexually Transmitted Disease History
History of sexually transmitted diseases:
Yes
No
If yes, give dates and treatment received Gonorrhea: _____________ Chlamydia: _____________ Syphilis: _____________
Herpes: ________________ HPV/Warts: ____________________________ Hepatitis: ________________________________
Do you feel you are at risk for HIV/AIDS? Yes No
Do you wish to be tested for HIV? (Confidential)
Yes No
Abnormal Pap Smear history
Any history of abnormal Pap smear: Yes No
When: ___________________________
What test did you have done: _________________________Any treatment: Yes No If yes, specify_____________________
Date of last Pap smear:
______________ Results: ___________________________
DES in Utero Exposure history:
Any history of DES exposure?
Yes
No
If yes, are you a:
DES daughter
DES mother
What problems have you had as a result of your DES exposure: ____________________________________________________
Medications: Are you currently on any medication?
Yes
No
Please list:
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Allergies: Medication allergies: (List drugs and reaction to them)
No allergies to any medications _______________
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Hospitalization: If you have a history of hospitalization, when and why? (List below)
No hospitalizations _________
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History of Blood transfusion?
Yes
No
If yes, when and why? ________________________________________
Review of Systems Do you have any of the following problems? (Circle) Describe all circled items I have none of these____
Unexplained weight gain/loss______
Shortness of breath______________
Nausea/Vomiting_______________
Fatigue________________________
Swollen ankles__________________
Constipation/Diarrhea____________
Vision problems________________
Palpitations____________________
Blood in stool__________________
Hearing problems_______________
Persistent cough________________
Change in bowel habits___________
Headache_____________________
Hay Fever_____________________
Excess hair growth/loss___________
Chest pain/chest tightness_________
Abdominal discomfort___________
Swollen Glands_________________
Lightheadedness________________
Indigestion____________________
Surgery
History of gynecological surgery?
History of other surgery?
If yes, give date, type of procedure and any complications:
If yes, give date, type of procedure and any complications:
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Medical history
Please circle if you have had problems with or are currently experiencing any of the following : Describe all circled items
High blood pressure_________________
Hepatitis or jaundice_________________
Gout_____________________________
Diabetes _________________________
Thyroid disease_____________________
Breast problems____________________
Cancer___________________________
Head or neck radiation_______________
Blood clots in legs__________________
Heart Disease______________________
Kidney disease_____________________
HIV/AIDS________________________
Stroke____________________________
Arthritis/Lupus_____________________
Epilepsy/seizures___________________
Rheumatic fever____________________
Low back problems_________________
Neurological disorders_______________
Asthma___________________________
Skin diseases______________________
Eating disorder_____________________
Bronchitis_________________________
Blood disorders____________________
Osteoporosis_______________________
Pneumonia________________________
Anxiety__________________________
Eye problems/glaucoma______________
Ulcers____________________________
Depression________________________
Hearing problems___________________
Hemorrhoid_______________________
Anemia___________________________
Elevated cholesterol _________________
Gall bladder disease_________________
Alcohol abuse______________________
Other_____________________________
Colitis____________________________
Drug Abuse________________________
Childhood illnesses, chicken pox,
measles
mumps
rubella
I have none of the above ____
Family history
Any family history of cancer?
Yes
No
If yes, list which family member (parents/siblings, children)
Breast ________________________________Cervix______________________Uterus_________________________________
Ovaries_______________________________ Lungs ______________________Colon __________________________________
Other ____________________________________________________________
Vaccination Status - Have you had all the usual childhood vaccinations? No Yes Were you vaccinated for HPV? No Yes
When was your last
Pap smear____________ Breast exam ___________ Stool check for blood _____________ Cholesterol check _______________
Mammogram ____________________ Colonoscopy__________________________
Social history:
Do you use:
Tobacco No
Yes
# packs/day _________ How long have you been smoking ______________
If you smoked in past when did you stop ___________________
Alcohol
Marijuana
Cocaine
No
Yes
Yes
Yes
Occasionally
Frequently (daily)
Weekend
No In past
No
In past
Other ___________________
What kind of work do you do? _______________________________________________________________________________