VIRGINIA PHYSICIANS FOR WOMEN NEW PATIENT HISTORY Name:______________________________________ Preferred/Nickname: __________________ D.O.B.: ____________ Marital Status:________________ Reason for visit: ________________________________________________________ Do you currently experience any of the following: Irregular periods? Y/N Pelvic or abdominal pain? Y/N Heavy periods? Y/N Abnormal vaginal discharge? Y/N Y/N Sexual problems? Y/N Bleeding between periods? Date of last menstrual period (first day): ____________ Age of very first period?_______ Age at menopause?________ How often do your periods usually occur? Every_______ days/months How many days do your periods last?______ Is the flow heavy, medium, or light? Do you use tampons or pads? How often do you have to change them? Every_________ minutes/hours Do you experience cramps? Y/N Would you describe them as mild/moderate/severe? Past Medical/Surgical History Do you have any medical problems such as Diabetes, high blood pressure, heart disease, thyroid disorder, cancer? Please list:_________________________________________________________________________________________ Have you ever had an STD?_____________________ History of physical/mental/sexual abuse?_____________________ Have you ever had any surgeries? Please list type and date__________________________________________________ __________________________________________________________________________________________________ Have you ever had an abnormal pap smear? Y/N What type of treatment was done?_____________________________ Date of most recent pap smear?_____________ Have you had an HPV test? Y/N Date____________ Results_________ Have you received the HPV vaccine (Gardasil or Cervarix)? (all 3 doses) Y/N Have you ever had a mammogram? Y/N Date of most recent?______________ Any abnormalities noted on mammogram or self breast exam? Y/N ______________________ Have you ever had a breast biopsy? Y/N Results___________________________ Do you smoke? Y/N How much?______________ Do you drink alcohol? Y/N How much?____________________ Do you use illegal drugs? Y/N How much?____________ Do you take any medications or over-­‐the-­‐counter medications (including vitamins)? Y/N Please list: ________________ _________________________________________________________________________________________________ Are you allergic to any medications or Latex? Y/N Please list medication and reaction: __________________________ __________________________________________________________________________________________________ Do you use any method for pregnancy prevention (including condoms, vasectomy, natural family planning)? Y/N Please describe: _________________________________ Obstetrical History How many times have you been pregnant? ______________ How many times have you given birth? ________________ Any twins or multiples? Y/N How many miscarriages/ectopic pregnancies have you had? _______________________ How many terminations/abortions have you had?____________ How many living children do you have? ____________ Please provide details about your previous pregnancies: Date of delivery How many wks along? How many hrs did labor last? Baby’s weight Male/female? Vaginal or C-­‐section? Epidural or none? Complications of Vacuum or forceps? Type of anesthesia? pregnancy or delivery? Location Family Medical History Do you have a family history of any of the following? Please list the affected family member(s) Diabetes Y/N __________________________ Breast cancer Y/N _____________________________ High blood pressure Y/N _______________________ Colon cancer Y/N _____________________________ High cholesterol Y/N __________________________ Endometrial (uterine) cancer Y/N ________________________ Heart disease Y/N __________________________ Ovarian cancer Y/N _____________________________ Thyroid disorder Y/N __________________________ Any other cancer Y/N _____________________________ Any other medical problems in family? Please list: _________________________________________________________ Review of Systems Do you experience any of the following symptoms on a regular basis? Fatigue Y/N Shortness of breath Y/N New skin lesions or rash Y/N Fever/chills Y/N Cough Y/N Muscular weakness Y/N Night sweats Y/N Nausea/vomiting Y/N Seizures Y/N Unintended weight gain Y/N Constipation Y/N Muscle/joint pain Y/N Unintended weight loss Y/N Diarrhea Y/N Anxiety Y/N Blurry vision Y/N Loss of appetite Y/N Depression Y/N Headaches Y/N Blood in stools Y/N Suicidal or homicidal thoughts Y/N Vertigo Y/N Change in appearance of stools Y/N Hallucinations Y/N Lightheadedness Y/N Urinary urgency /frequency Y/N Irregular heartbeat Y/N Breast lump Y/N Pain with urination Y/N Chest pain Y/N Breast swelling Y/N Incontinence Y/N Palpitations Y/N Breast pain Y/N Pain with intercourse Y/N Easy bleeding/bruising Y/N Nipple discharge Y/N Decreased libido Y/N Lymph node enlargement Y/N If you answered yes to any of the above, please describe: _________________________________________________