Kaufman Women’s Health Center
Michael T Glover DO
New Patient Health History
1. Please state briefly the reason for your visit with us today:
2. Are you having Menstrual Cycles? YES NO If not, when did you stop? ______________________________________
If you answered no to this question then skip to question #11
3. When was the first day of your last menstrual cycle? ________________________________________________________
4. Are your periods fairly regular? YES NO
5. How many days does your period normally last? ___________ 6. How many of those days are heavy? _______________
7. How many days do you average from the first day of your cycle to the first day of your next cycle? ________________
8. Do you bleed excessively or pass large clots? YES NO
9. Do you have an excessive amount of discomfort or cramping with your periods? YES NO
10. Are you currently using any birth control? YES NO please circle whatever applies:
Birth Control pills
Depo-Provera
Nuvaring
Ortho-Evra
Mirena
Paragard
Tubal ligation
Vasectomy
11. Please list the names and birthdates of the children that were born to you
1. ____________________________________________________ full term premature birth date _______________
2. ____________________________________________________ full term premature birth date _______________
3. ____________________________________________________ full term premature birth date _______________
4. ____________________________________________________ full term premature birth date _______________
5. ____________________________________________________ full term premature birth date _______________
6. ____________________________________________________ full term premature birth date _______________
12. Do you smoke cigarettes? YES NO
How many per day? _____________ How old were you when you started? _____
13. Do you drink alcoholic beverages? YES NO If yes how much and how often? ___________________________________
14. Do you have any history of using any illegal drugs or abusing prescription medication? YES NO
15. Please list below any medications that you take on a regular basis:
16. Please list below any medications that you are allergic to:
17. Please circle below the medical problems that you currently have or have had in the past:
Aids/HIV
Breast Cancer
Drug abuse
Hepatitis
Sickle Cell Disease
Alcohol Abuse
Cancer of the Cervix
Emphysema
High Blood Pressure
Stroke
Anemia
Cancer of the Ovary
Diabetes
High Cholesterol
STD’s
Asthma
Cancer of the Uterus
Epilepsy
Gastroesophageal Reflux Thyroid disease
Bleeding Diseases
Colon Cancer
Glaucoma
Kidney Disease
Tuberculosis
Breast Lumps
Depression
Heart Disease Rheumatic fever
Rheumatoid Arthritis
Osteoporosis
Kidney Stones
Other: __________________________________________________________________________________________________
18. What Surgeries have you had in the past? Please give approximate dates
Tubal Ligation
Cesarean Section
Hysterectomy
Cone Biopsy
Endometrial ablation
LEEP
Appendectomy
Gall Bladder Surgery
Breast Biopsy
Breast Implants
Mastectomy
Heart Surgery
Bladder Repair
Back Surgery
LASIK
Bone and Joint Surgery
Carpal Tunnel Surgery
Cataract Surgery
Plastic Surgery
Other:
______________________________________________________________________________________________________
19 Family History:
a. Mother LIVING DECEASED Current age or age at the time of death: _______________________________________
Chronic Health Problems or cause of death: ________________________________________________________
b. Father LIVING DECEASED Current age or age at the time of death: _______________________________________
Chronic Health Problems or cause of death: ________________________________________________________
c. Please list Chronic Health Problems or causes of death for your brothers and sisters: _____________________________
____________________________________________________________________________________________________
d. Please circle any of the following diseases that close relatives struggle with, (grandparents, aunts, uncles or children)
Breast Cancer
Ovarian Cancer
Cervical Cancer
Cancer of the Uterus
Lung Cancer
Colon Cancer
Drug Abuse
Heart Attack below 60
Bleeding Diseases
Sickle Cell Disease
High Blood Pressure
Epilepsy
Alcohol Abuse
Stroke
HIV/AIDS
Psychiatric Illnesses
Kidney Disease
Diabetes
Glaucoma
Osteoporosis
Other: _____________________________________________________________________________________
Review of Systems
20. Are you frequently overly fatigued?
21. Has your weight changed more than 10# in the last year?
22. Do you regularly have trouble sleeping well? YES NO
YES NO
YES NO
23. Do you have any unusual skin rashes, lesions or moles that you would like for me to look at?
24. Do you have any chronic skin conditions such as psoriasis?
25. Do you have problems with chronic upper respiratory allergies?
26. Do you currently have a problem with sore throat, runny nose or sinus congestion?
27. Do you have any chronic visual disturbances?
28. Do you wear corrective lenses?
29. Do you have any hearing difficulties?
30. Do you have frequent nose bleeds?
YES
YES
YES
YES
YES
YES
YES
YES
31. Do you have any history of thyroid disease?
32. Do you have a history of any significant neck injuries?
YES NO
YES NO
NO
NO
NO
NO
NO
NO
NO
NO
gained lost
33. When was the last time that you had a mammogram? ____________________________
34. Do you regularly perform self breast examination?
35. Have you noticed any new lumps or bumps in your breasts?
36. Do you have any bleeding or discharge from your nipples?
YES NO
YES NO
YES NO
37. Do you have any trouble with shortness of breath, wheezing or coughing?
38. Do you have problems with chest pain or tightness in the chest?
39. Do you have any history of High Blood Pressure?
40. Have you ever had rheumatic fever?
41. Do you have problems with varicose veins?
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
42. Do you have frequent problems with heartburn or indigestion?
YES
43. Do you have any problems with swallowing?
YES
44. Do you have frequent episodes of nausea or vomiting?
YES
45. Do you have frequent problems with constipation?
YES
46. Do you have frequent problems with diarrhea?
YES
47. Do you have blood with your bowel movements?
YES
48. Do you have problems with hemorrhoids?
YES
49. When was your last PAP smear? _____________________________________________
50. Have you had problems in the past with abnormal PAP smears?
YES
51. Do you have burning or pain with urination frequently?
YES
52. Do you have excess urgency to urinate or feel that you have the need to urinate too frequently? YES
53. Do you get out of bed most nights to urinate more than once?
YES
54. Do you leak urine when you laugh, cough, sneeze, jog etc.?
YES
55. Do you notice blood in your urine, (other than when menstruating)?
YES
56. Are you currently sexually active?
YES
57. Do you have significant pain or discomfort with intercourse?
YES
NO
NO
NO
NO
NO
NO
NO
58. Do you have problems with joint pain, stiffness or arthritis?
59. Do you have a history of rheumatoid arthritis?
60. Do you have problems with back pain or prior back injuries?
61. Do you have any history of osteoporosis?
62. Have you ever been tested for osteoporosis?
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
63. Do you have problems with headaches that are not relieved by Tylenol, Advil or Alleve?
64. Do you have problems with fainting episodes or unexplained dizzy spells?
65. Do you have any history of seizures?
66. Do you have a history of depression currently or in the past?
67. Do you have a history of any other psychiatric illness?
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
Please list other physicians that you have seen in the last year:
NO
NO
NO
NO
NO
NO
NO
NO