Women’s Healthcare Associates of Santa Monica
1245 16th Street, Suite 300
Lillian Morris, M.D., F.A.C.O.G.
Santa Monica, CA 90404
Tel 310-453-6767 Fax 310-828-3704
Doron Blumenfeld, M.D., F.A.C.O.G.
Olivia Crookes, M.D., F.A.C.O.G.
Health History:
Last Name:___________________First Name:____________________ MI:____ Date:____________
DOB:_______________ Age:_______
Primary Care Physician:____________________________
Emergency Contact:___________________ Relationship:______________ Phone#:_______________
Past Medical/Surgical History: (i.e. Endometriosis, Ovarian Cyst, Hospitalizations, Surgeries, etc.)
Illness
Year
Illness
Family History: (Please list serious illnesses in your immediate family)
Illness
Illness
Heart Disease/Heart Attack
Y
N
Diabetes
Y
N
Cancer
Y
N
Y
N
Social History: (If Appropriate)
Do you drink alcohol? Y N If so, how much?
Do you or someone in your household smoke? Y N If so, how much?
Living Arrangements: Husband Children Other
Education Level: HS College Grad School
Please check if you have recently experienced any of the following:
General
Respiratory
GI
Trouble sleeping
Cough
Nausea
Always tired
Shortness of breath
Vomiting/dry heaves
Loss of appetite
Breathing discomfort
Heartburn
Weight loss
Wheezing
Bloating
Weight gain
Snoring
Constipation
Recurrent infection
Sleep apnea
Diarrhea
Excessive thirst
Loose stools
Fever
Black/bloody
stools
CVS
Chills
Chest pain
Rectal bleeding
Night sweats
Palpitations
Abdominal pain
Hot flashes
Discomfort in chest
Calf/leg pain
GU
Ankle swelling
Excessive urination
HEENT
Hay fever
Urinary urgency
Sinus pain
Pain
with urination
Musculoskeletal/Extremities
Blurred vision
Difficulty with urination
Eye pain
Stiffness in muscles
Blood in urine
Red eyes
Stiffness in joints
Waking to urinate
Watery eyes
Muscle aches
Weak stream
Itchy eyes
Stiff neck
Pelvic pain
Hearing loss
Back pain
Irregular periods
Ear pain
Neck pain
Vaginal yeast infections
Ear drainage
Ringing in ears
Last Pap:
Lymphatic/Heme
Runny nose
Last Period:
Congested nose
Easy bruising
# of Pregnancies:
Hoarseness
Free bleeder
# of Live births:
Swallowing pain
Sore throat
Other:
Other:
Year
Y
Y
Y
Y
N
N
N
N
Skin/Breast
Rash
Lesions/moles
Recurrent boils
Discoloring
Irregular growth
Itching
Breast pain
Discharge from nipples
Neurological
Blackouts
Headache
Dizziness
Poor balance
Memory loss
Tremors
Visual disturbances
Tingling/numbness
Paralysis
Weakness in hands/feet
Psychiatric
Anxiety
Fear
Depression
Change in behavior
Loss of interest in hobby
Difficulty concentrating