Rady Children's Hospital - San Diego
3020 Children’s Way
San Diego, CA. 92123
PATIENT INFORMATION
Name:
MR#:
Finance:
*DTF1
DOB:
377*
MD:
DTF1377
GYNECOLOGY NEW PATIENT MEDICAL HISTORY
Patient Name: ______________________________________________ Date of Birth: ____________
What brings you in today?
How long have you had this problem?
WHAT HAS BEEN DONE THUS FAR FOR THIS PROBLEM
Lab Test - Which ones:
When:
Where:
None
Ultrasounds- Which ones:
When:
Where:
None
MRI/CT Scans- Which ones:
When:
Where:
None
Medicine- Which ones:
When:
Where:
None
If medication was/is being taken, was/is helping:
For how long:
HISTORY OF PATIENT’S BIRTH HISTORY
Mother’s pregnancy with patient was:
FULL TERM / ENDED EARLY
If ended early, @ ___________ week’s gestation
Delivery was: Vaginal / Scheduled C-Section/ Emergency C-Section
Complicated pregnancy or delivery: YES or NO
If yes, please explain:
Medication taken while pregnant: YES or NO
If yes, which ones:
PAST MEDICAL HISTORY
Hospitalizations:
What:
When:
None
Surgeries:
What:
When:
None
Psychological Care:
Why:
When:
None
GYNECOLOGY HISTORY
Age of first period:
Periods occurring monthly: YES or NO
If no, how frequent:
How many days do you bleed?
How often do you change your pad/tampon: _______ / hours?
Do you leak onto clothing: YES or NO
Do you have severe menstrual cramps:
If yes, are you missing school due to cramping:
If yes, how often: At night only / Daily/ Intermittently
YES or NO
YES or NO
Are you unable to participate in extracurricular activities due to cramping:
YES or NO
FAMILY HISTORY
Has any blood-related family members had problems concerning the following
Cervical Cancer:
YES or NO
If yes, Who:
Infertility:
YES or NO
If yes, Who:
Bleeding Disorder:
YES or NO
If yes, Who:
Breast Cancer:
YES or NO
If yes , Who:
Developmental Delay: YES or NO
If yes, Who:
Diabetes:
YES or NO
If yes, Who:
Painful Menses:
YES or NO
If yes, Who:
Heavy Menses:
YES or NO
If yes, Who:
Ovarian Cancer:
YES or NO
If yes, Who:
DVT/ PE :
YES or NO
If yes, Who:
Endometriosis:
YES or NO
If yes, Who:
How was it diagnosed:
SOCIAL HISTORY
Patient’s parents are: Married / Unmarried / Divorced / Separated / Widowed / One parent is deceased
Who does patient live with:
Brother (s) / Age:
Sister (s) / Age:
Attends School:
YES or NO
Grade:
Overall school performance:
Attends after school programs: YES or NO
Extracurricular activities: YES or NO
what types:
Experiencing new changes or stresses: YES or NO
Explain:
REVIEW OF SYSTEMS
Hematologic (blood) System:
Endocrine (Hormonal) System:
Neurological (Nerves/Head) System:
Integumentary (Skin) System:
Cardiac (Heart) System:
Gastrointestinal (Stomach/Intestinal) System:
Respiratory (Lungs) System:
Musculoskeletal System (muscle/bone):
HEENT (head/eyes/throat):
Psychological (Moods/Behavior):