PatientPop



Name: ____________________________________________Date: _____________________________Reason for your visit: ____________________________________________________________________________Medical HistoryAllergies:Are you allergic to any medication?YesNoLatex Allergy? YesNoName of Medication(s)Reaction: (rash, itching, shortness of breath, nausea, Etc.)____________________________________________________________________________________________Medications: (List any medications you are presently taking including vitamins/supplements)______________________________________________________________________________________________________________________________________________________________________________Social History:Tobacco use currently:YesNo If yes, how much per day? ____________________________________Tobacco use in the past:YesNo If yes, when did you stop smoking ______________________________Vaping:YesNoIf yes, how much per day? _____________________________________Alcohol use:YesNoIf yes, how much per day/week _________________________________Street Drug useYesNoMarijuana Cocaine Methamphetamine Opioids Other: __________Do you exercise regularly?YesNoType of exercise? ____________________________________________Do you experience sleep YesNoHow often? ________________________________________________problems?Marital Status(circle): Married Single Divorced Widowed Committed Relationship Religious Affiliation (optional): ____________________________Personal Surgical History (Please give date):Appendectomy__________________________Gall Bladder _____________________________________Breast Biopsy Left/Right___________________Heart Surgery (type) _______________________________Breast Reduction ________________________Hysterectomy Vaginal/Abdominal ____________________Breast Augmentation _____________________LEEP/Conization ___________________________________Colonoscopy (colon scope) _________________Removal of Ovaries ________________________________Name: ____________________________________________Date: _____________________________C-Section __________(Indicate number) ____Sterilization ______________________________________Reason for C-Section________________________D & C __________________________________Tonsillectomy _____________________________________Endometrial Ablation _____________________Other ____________________________________________Personal Medical History: (Circle if applies)Cancer (indicate type)GastrointestinalInfectious DiseasePulmonaryBreastCrohn’s DiseaseChicken PoxAsthmaCervicalUlcerative ColitisShinglesCOPD/EmphysemaColonGallbladder DiseaseHIVSeasonal AllergiesEndometrialGERD (Reflux)Tuberculosis/PositiveLungIrritable Bowel Syndrome (IBS)PPDRheumatologyOvarianLiver DiseaseRubellaArthritisOther______________HepatitisCytomegalovirusFibromyalgiaUlcerMRSALupusCardiovascularHematologyNeurologyUrologyHigh Blood PressureAnemiaAlzheimer’s/DementiaFrequent UTI (UrinaryHigh CholesterolBlood Clotting DisorderHeadache/Migraines/Auratract infection)Heart AttackBlood TransfusionStrokeHematuria (blood inMitral Valve ProlapseDVT (Deep Vein Thrombosis)Epilepsyurine)Rheumatic FeverPE (Pulmonary Embolism/Multiple SclerosisKidney DiseaseVaricositiesclot in lung)Kidney InfectionSickle Cell Disease/TraitIncontinenceEndocrinologyPsychiatricDiabetes Mellitus (during pregnancy)ADD/ADHDDiabetes Mellitus (non-insulin dependent)AnxietyDiabetes Mellitus (insulin dependent)BipolarHypo/Hyper thyroidDepressionPolycystic Ovarian SyndromeEating DisorderOsteoporosisPanic AttacksOsteopeniaObstetrical History:Total # of Pregnancies? ___________Live full-term births? _____________Premature births? ____________Miscarriages? __________Induced abortions? ______________Stillbirths? _______________Name: ____________________________________________Date: _____________________________Please list your pregnancies in order including miscarriages and abortionsDateHospitalType of DeliveryWeeksInfant WeightNameSexComplications1.2.3.4.5.GYN History:Date of most recent Pap Smear: ________________________NormalAbnormalDon’t knowDate of most recent Mammogram: ______________________NormalAbnormalDon’t knowDo you perform self-breast exams regularly?YesNoDate of last Colonoscopyor Colon Cancer screening? ____________________Date of most recent Bone Density: _____________________History of: (Please circle all items that apply)Abnormal Pap SmearOvarian ProblemsChlamydiaGroup B StrepDescribe: _____________________PCOSGonorrheaHIVHPV/Genital WartsInfertilityTrichomonasMRSAEndometriosisBacterial VaginosisHerpes SimplexFibroids Yeast InfectionSyphilisAre you Sexually active? Yes NoDo you have sexual concerns to discuss with the provider today? YesNoWhat is your sexual Orientation? Heterosexual Homosexual Bi-Sexual Other: _____________________________Current birth control method: _________________________Number of lifetime sexual partners? ____________Are you happy with your method of birth control?YesNoMenstrual History:First day of last menstrual period: ____________Age started menstrual cycle: ______________________If Menopausal, give year: _____________Name: ____________________________________________Date: _____________________________# of days of bleeding with your period: _______# of days from start of one period to the start of the next _____Flow is: Mild Moderate HeavyMenstrual Cramps: None Mild Moderate SevereBleed between periods: YesNoPsychosocial History:Do you feel safe at home and work?Yes NoDo you have someone to turn to for support?YesNoHave you ever been forced into any sexualactivity against your will?YesNoAre you afraid of your partner oranyone else?YesNoImmunization History: Have you been vaccinated for the following?DPTYesNoChicken PoxYesNoHPVYesNo PolioYesNoInfluenzaYesNo(If yes were all 3 doses received?)MMRYesNoPneumoniaYesNoDates: __________________________HepatitisYesNoTetanus BoosterYesNoFamily Medical History: (Please indicate relationship: Mother, Father, Sister, Brother, Maternal/Paternal Grandmother, Etc.)Are you adopted?YesNoHas anyone in your family had any of the following health problems? If yes, give details?CancerYesNoWhom: ______________________________High CholesterolYesNoWhom: ______________________________OsteoporosisYesNoWhom: ______________________________Birth DefectsYesNoWhom: ______________________________DiabetesYesNoWhom: ______________________________Diabetes in PregnancyYesNoWhom: ______________________________HypertensionYesNoWhom: ______________________________HypertensionYesNoWhom: ______________________________in Pregnancy Heart DiseaseYesNoWhom: ______________________________Other: _____________________________________________________________Have you ever been tested for Hereditary Cancer? YesNoAre you or your partner of Jewish Descent? Yes NoInternational travel this year?YesNoIf yes when/where? ______________________Do you have a Primary Care Provider? ________________________________________Have you had any recent labs done elsewhere? _________________________________________________ ................
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