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 | |
| | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| 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 | | |
| | | |
| | | |
| | | |
| | | |
| | | |
|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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