GYNECOLOGICAL/MENSTRUAL/PREGNANCY HISTORY



-533400001973580-66040Student AffairsStudent Health Services00Student AffairsStudent Health ServicesWOMEN’S HEALTH CLINIC: HEALTH HISTORY FORM NAME_______________________________ SUNY ID_____________DOB___/___/___AGE_____ Last First M.I. Mo. Day YearGYNECOLOGICAL/MENSTRUAL/PREGNANCY HISTORYAge of first menses: _____ Does your menses come monthly? _____ Are they Heavy? _____How many pads/tampons do you use on your heaviest day? _____ Are they painful? _____When was your last GYN exam? _____ Last STI screen? _____ Last Pap Smear? _____Are you currently or ever been sexually active? _____Have you ever been diagnosed with a sexually transmitted infection? _________If yes, explain: _______________________________________________________________________Have you ever had an abnormal pap smear? _______If yes, explain: ____________________________________________________________________Have you ever been pregnant? ____ # live births ___ #abortions/miscarriages ____ Stillbirths____ Have you ever had or have current GYN problems? _____ Explain:_____________________________ ____________________________________________________________________________________Did you have the Gardasil vaccines? _____. If yes,When:______________________________________CONTRACEPTIVE HISTORY Do you use condoms to protect from STI’s and/or to prevent pregnancy? _____Are you using any other birth control method now? ____ If yes, what: ___________________________What methods have you used in the past? __________________________________________________Reason for changing methods: ___________________________________________________________MEDICAL HISTORY Have you had any of the following? (Check only ones you have or had)YES YESYES_____ Migraine headaches _____Breast disease_____ Stroke_____ Epilepsy _____ Severe depression_____Thyroid problems_____ Liver disease/Hepatitis _____ Heart disease/Murmur _____ High blood pressure_____ Blood clots/blood disorders _____ Stomach/bowel problems_____Gall bladder problem _____Asthma/breathing problems _____ Kidney/Bladder problems_____ CancerCOMMENTS: _________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________SURGICAL HISTORY (record surgeries including dates)_____________________________________________________________________ _____________________________________________________________________FAMILY HISTORY (PARENTS AND SIBLINGS) Unsure NO YES WHO Unsure NO YES WHODiabetes _______ ___ __________ High Blood Pressure ____ ___ ___ _________Stroke ____ ___ ___ __________ Breast Disease ____ ___ ___ _________Cancer ____ ___ ___ __________ Osteoporosis ____ ___ ___ _________Heart Attack ____ ___ ___ __________ Hereditary Disease ____ ___ ___ __________________________________________________Reviewed_____________________________STUDENTS SIGNATURE DATE D. Walker NP/ D. Hirt NP DATERevised 8/2015 ................
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