Ethan Frome - Planned Parenthood



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|Contraceptive History |

|Circle all the birth control methods |Please describe any problems you had |

|that you have ever used. |with any method. |

|C-Cap/diaphragm/sponge | |

|Condom, male or female | |

|Cream/film/foam/suppository | |

|Depo | |

|IUD | |

|Natural family planning | |

|Norplant | |

|Implanon | |

|Pills | |

|Tubal ligation | |

|Vasectomy | |

|Other:______________________ | |

| Pregnancy History |

|No Yes |

|Do you plan to have children / more children? | | |

|Have you ever been pregnant? (If no, skip to next section) | | |

|Did you have diabetes during your pregnancy? | | |

|Any children with genetic abnormalities/birth defects? | | |

|Are you currently pregnant? | | |

|Please list the ages of your |Number of: Pregnancies | |

|living children. |Live births | |

| |Vaginal deliveries | |

| |C-section deliveries | |

| |Fetal Deaths | |

| |Stillbirths | |

| |Miscarriages | |

| |Abortions | |

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| Family History |

|No Yes |

|Are you adopted? (If yes, skip this section as appropriate) | | |

|Did your mother ever take DES or hormones when she was pregnant with| | |

|you? | | |

|Has your biological Breast | | |

|cancer | | |

|mother, father, Cervical / ovarian | | |

|cancer | | |

|sister or brother | | |

|Diabetes | | |

|ever had: Early heart attack or stroke (< age 55 for males) | | |

|(< age 65 for females) | | |

|High cholesterol | | |

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|Personal History No Yes |

|Do you smoke? (If yes: _____ years, ____ cigarettes/day) | | |

|Do you drink alcoholic beverages? (If yes: ___ drinks/day) | | |

|Do you use drugs? What kind?_______ Injectable?______ | | |

|Are you being physically, mentally or sexually abused by a member of| | |

|your household or a relative? | | |

|Do you feel safe at home? | | |

|Are you being abused by someone other than a member of your | | |

|household or a relative? | | |

|Allergies No Yes |

|Do you have any drug allergies? | | |

|ALLERGIES: |

|[ ] aspirin [ ] erythromycin [ ] sulfa |

|[ ] antispetic [ ] iodine [ ] tylenol |

|[ ] cipro [ ] latex [ ] other |

|[ ] copper [ ] lindane |

|[ ] doxyclycline [ ] penicillin |

|Do you have a history of any adverse drug reactions? | | |

|DRUG REACTIONS: (Please give details) |

|Medical Treatment No Yes |

|Have you received medical care elsewhere in the past 6 months? | | |

|Are you being treated for any condition currently? | | |

|If yes, please explain: |

|Have you taken any over the counter or prescribed medications in the| | |

|past 2 months? | | |

|The information I have given on this form is correct to the best of my |

|knowledge. |

|Signatures Date |

|Patient: | |

|Staff / Title: | |

MEDICAL & SOCIAL HISTORY

FEMALE PATIENT

|Medical/Surgical History |

|Have you ever had any of the following|No |Yes |Specify |

|conditions? | | | |

|Anemia | | | |

|Cancer | | | |

|Depression/Anxiety/Suicidal | | | |

|Thoughts/Bipolar | | | |

|Diabetes | | | |

|Eye problems | | | |

|Genetic condition/birth defects | | | |

|Heart disease | | | |

|High blood pressure | | | |

|High cholesterol | | | |

|Liver or gallbladder disease | | | |

|Neurologic conditions | | | |

|(stroke, migraine headaches) | | | |

|Measles/mumps/rubella/mono | | | |

|Seizure disorder | | | |

|Sensory difficulties (numbness) | | | |

|Thrombophlebitis (blood clots) | | | |

|Ulcers/spastic colon | | | |

|Urinary tract conditions | | | |

|(kidney, bladder, urethra) | | | |

|Have you ever had surgery, | | |Give Specifics |

|hospitalizations, | | | |

|blood transfusions? | | | |

|GYN History |

|Breast disease | | | |

|Breast cancer | | | |

|Cervical/ovarian/uterine cancer | | | |

|Pelvic infection | | | |

|Sexually transmitted infection (AIDS, | | | |

|chlamydia, condyloma, genital warts, | | | |

|gonorrhea, herpes, syphilis, | | | |

|trichomonas, Hep. B) | | | |

|Uterine abnormality | | | |

|PAP History |

|Abnormal PAP | | | |

|Treatment: (please circle) cautery, colposcopy, cone biopsy, |Date: |

|cryosurgery, Laser, LEEP, no treatment | |

|Menstrual/Sexual History |

|How old were you when you started your period? | |

|How often are your periods? (in days) | |

|How many days does your period last? | |

|On average, how many tampons/pads do you use each day during your | |

|period? | |

| No Yes |

|Do you spot between periods? | | |

|Do you have severe cramping during your periods? | | |

|Have you ever had sex? Age at 1st intercourse:_____ | | |

|Are you sexually active now? (If yes, check all that apply) | | |

| Vaginal intercourse [ ] , Anal intercourse [ ], Oral sex [ | | |

|], | | |

|Outercourse (stimulation without penetration) [ ] | | |

|Have you had sex with a [ ] Man [ ] Woman [ ] Both | | |

|Has your partner had any of the following? (Check all that | | |

|apply) | | |

|Multiple partners[ ], Hx of STD [ ], HIV [ ], | | |

|Used injectable drugs [ ] | | |

|Has your partner had sex with a | | |

|[ ] Man [ ] Woman [ ] Both | | |

|Number of sex partners in your life? MEN ____ WOMEN ____ |

|Do you currently have more that one partner? | | |

|Have you changed partners recently (last 6 months)? | | |

|Do you and your partner only have sex with each other? | | |

|Are you having sex because you want to? | | |

|Are you having sex because someone is forcing you? | | |

|Do you have bleeding during or after sex? | | |

|Is sex painful for you? | | |

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Patient Name: ______________________

Patient No.:________________________

D.O.B.:____________________________

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