Reproductive Health Associates, P.A.
Personal History
Name _________________________________________
Last
First
Name you prefer to be called
Allergies: [
Birthdate __________________
MI
] No Known Allergies
MM/DD/YYYY
________________________
Hospitalizations:
[
] None
Medications / Food / Environment & Reaction
Problem / Procedure
________________________
________________________
__________________________
__________________________
Medications: [
] None
(Please list all medications including Prescription, OTC and Herbs)
Medication
Dosage
_______________________
_______________________
_______________________
Past Medical History:
___
___
___
___
___
___
___
___
___
___
___
___
___
Date
Started
_____________ ____________
_____________ ____________
_____________ ____________
( Check all that apply )
Anemia
Abnormal wt gain/loss
Depression
Migraines
Seizures
Asthma
Tuberculosis
Chronic Lung Disease
Hyperthyroid
Hypothyroid
Diabetes
Osteoporosis
Arthritis
___ High Blood Pressure
___ Heart disease
___ Stroke
___ Mitral Valve Prolapse
___ Blood Clots
___ Varicose Veins
___ Urinary Tract Infections
___ Kidney Stones
___ Interstitial Cystitis
___ Sickle Cell Trait/Disease
___ Von Willebrands
___ Use of Steroids
___ Use of Anticoagulants
Menstrual History:
___ Cancer TYPE ______________
___ Crohn’s Disease
___ Irritable Bowel
___ Hepatitis
___ Uterine Fibroids
___ Abnormal Uterine Bleeding
___ Poly Cystic Ovarian Syndrome
___ Bartholin Gland Cyst
___ Abnormal PAP
___ Colpo Year __________
___ LEEP
Year __________
___ Other ____________________
___ Other ____________________
Menopause History:
Age of first period
Length of period
Interval between periods
_______ years
_______ days
_______ days
Age of last period
Date of last period
____________ years
____________
Gynecology History:
Last menstrual period __________________
Last mammogram __________________
Sexually active:
Y/N
Last PAP smear _________________ Results _________
Dexa Scan ______________
Colonoscopy ____________
Number of sexual partners: at present _____ Lifetime ______
Present birth control: Pill ________ Nuva Ring ___ Tubal Ligation ___ IUD ___ Depo ___ Condoms ___
Past Birth Control: Pill __________ Nuva Ring ___ Tubal Ligation ___ IUD ___ Depo ___ Condoms ___
History of Sexually Transmitted Infections:
Chlamydia ____ Gonorrhea ____
[
] NONE
HPV ____ Herpes ____ Syphilis ____ Other ______
Patient Name: ____________________
Pregnancy History:
Number of:
Full term (>37 weeks) _______
Premature (<37 weeks) _______
Cesarean Sections
_______
Date
_______
_______
_______
_______
Live at birth
_______
Live at present
_______
Vaginal Deliveries _______
Sex
Weeks
Weight
Vag or C/S
Hrs of Labor
____
____
____
____
______
______
______
______
______
______
______
______
________
________
________
________
__________
__________
__________
__________
Miscarriages ________
Abortions
________
Ectopic
________
Complications
______________________
______________________
______________________
______________________
Social History:
Primary Language
_________________________
Marital Status
S/M/D/W
Activity Level:
Vigorous ___ Moderate ___ Sedentary ___
Diet History:
Healthy ___ Moderate ___ Poor ___ Diabetic ___ Vegetarian ___
Religious Affiliation:
_______________________________________________________________
Safety:
Smoke Detectors Y / N
Do you wear Seatbelts Y / N
Hx of Physical Abuse _______________________
How often? ______________
Sexual Abuse ___________________________
Are you in a relationship with a person who has threatened or physically hurt you?
Tobacco:
Y / N / Quit
Packs / Day _____________
Alcohol:
Y / N / Quit
Rare ___ Occasional ___ Monthly ___ Daily ___
Recreational Drug Use:
Family History:
[
Mother’s Age ______
Deceased Y / N
Cause ____________
Father’s Age_______
Deceased Y / N
Cause ____________
Cancer / Location
Diabetes
Thyroid
Heart Disease
High Blood Pressure
High Cholesterol
Stroke
Hepatitis
Kidney Disease
Osteoporosis
Other
Y / N / Quit
]
Y/N
Substance _______________________________________
Adopted (no family history)
Siblings (M/F)
__________
__________
__________
Age
____
____
____
Deceased/Cause
________________________
________________________
________________________
Children (M/F)
___________
___________
Age
____
____
Deceased/Cause
_________________________
_________________________
Family Member
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Patient Signature: _______________________________________ Date: ______________________________