AGE______
AGE______ DATE____________
MEDICAL HISTORY: PLEASE ANSWER THESE HISTORY QUESTIONS. HAVE YOU OR ANY MEMBERS OF YOUR FAMILY EVER HAD:
YOU FAMILY DESCRIBE
HEADACHES OR NERVOUS DISORDER
THYROID PROBLEM
HEART PROBLEM/HIGH BLOOD PRESSURE
LUNG DISORDER
BREAST PROBLEMS
JAUNDICE, HEPATITIS, LIVER PROBLEM
STOMACH, BOWELL GALLBLADDER PROBLEM
KIDNEY OR BLADDER PROBLEMS
FEMALE OR SEXUAL PROBLEMS
ALLERGIES OR DRUG SENSITIVITIES
ANEMIA OR BLOOD DISORDERS
A BLOOD TRANSFUSION
DIABETES
CANCER
BIRTH DEFECTS OR INHERITED DISEASES
OTHER MEDICAL PROBLEMS
NO KNOWN MEDICAL PROBLEMS
HAVE YOU EVER HAD ANY STD’S (IE: SYPHYLLIS, GONORRHEA, CHLAMYDIA, HERPES, HPV)? ________________
HAVE YOU EVER HAD AN ABNORMAL PAP SMEAR? ____ IF YES, HOW WAS IT TREATED? ______________________
HOSPITALIZATIONS: PLEASE LIST THOSE PREGNANCY HISTORY: PLEASE LIST THE #
OPERATIONS OR SERIOUS ILLNESSES TIMES PREGNANT ______
THAT YOU HAVE HAD WHICH REQUIRED MISCARRIAGES_____ TERMINATIONS___
HOSPITALIZATION: PREMATURE_____LIVING CHILDREN____
YEAR PLACE BABY SEX WKS. TYPE OF ANY
YEAR ILLNESS/OPERATION PROBLEMS BORN BORN WGHT PREG. DELIV. PROB.
__________________________________________________________________________________________________________
_______________________________________________ ____________________________________________________
_______________________________________________ ____________________________________________________
_______________________________________________ ____________________________________________________
_______________________________________________ ____________________________________________________
MENSTRUATION: MEDICATIONS: PLEASE LIST ALL
WHAT WAS THE DATE OF YOUR LAST MENSTRUAL PERIOD? ___________ CURRENT MEDICATIONS:
HOW OLD WERE YOU WHEN YOU FIRST BEGAN MENSTRUATING? _______ __________________________________
HOW MANY DAYS PASS BETWEEN THE FIRST DAY OF EACH PERIOD? ____ __________________________________
HOW MANY DAYS DOES YOUR PERIOD USUALLY LAST? _______ __________________________________
ARE YOUR PERIODS USUALLY PAINFUL? _______ __________________________________
DO YOU USE BIRTH CONTROL? ___________ __________________________________
IF YES, WHAT METHOD? ______________________________ __________________________________
HAVE YOU EVER HAD COMPLICATIONS WITH BIRTH CONTROL? _______ __________________________________
HAVE YOU EVER HAD ANY DIFFICULTY BECOMING PREGNANT? _______ __________________________________
ARE YOU ALLERGIC OR REACT POORLY TO ANY MEDICATIONS? _____________________________
IF YES, PLEASE LIST: ______________________________________________________________________________________
PSYCHOSOCIAL:
DO YOU SMOKE? ____ #PER DAY_____ DO YOU DRINK ALCOHOL? ______ CONSUMPTION? ______________________
ARE YOU UNDER THE CARE OF ANY OTHER PHYSICIANS? _______ IF YES, PLEASE INDICATE NAMES: ___________
___________________________________________________________________________________________________________
PLEASE ADD ANY ADDITIONAL PERSONAL OR FAMILY INFORMATION YOU FEEL WOULD BE HELPFUL: _________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
_______________________________________ ____________________________________________
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