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MEDICAL HISTORY

Name:__________________________________________________

Date of Birth:____________________ Age______

Today’s Date:___________________

Yes No N/A

1 Adopted. If Birth family history unknown, go to section A

2 If born before 1971, did your mother take DES while she was pregnant with you?

LIST only blood-related Mother (M), Father (F), Sister (S), Brother (B) who have had any of the following:

Yes No Who

3 High cholesterol ____________________

4 Diabetes ____________________

5 High Blood Pressure ____________________

6 Q Breast or Ovarian Cancer ____________________

7 Other Cancer ____________________

8 Heart attack/disease before age 50 ____________________

9 Stroke ____________________

10 Genetic problems ____________________

11 Osteoporosis ____________________

12 Blood Clots ____________________

13 Other:________________________________________________

14 Currently or in the past, have you taken hormones for gender or sex transitioning purposes? If yes, what? _________________________________

15 Allergies (medications, metals, latex, or anesthesia) NONE

List: ________________________________________________________

16 Medications currently taking (include herbs / vitamins) NONE

List: ________________________________________________________

17 Vaccinations Check if you have had the following vaccines:

Tetanus Varicella (chicken pox)

Diphtheria Pneumococcal

Hepatitis A Meningococcal

Measles/Mumps/ Rubella MMR Other: ___________________

Hepatitis B: 1st dose 2nd dose 3rd dose

Vaccine for HPV (Gardasil®): 1st dose 2nd dose 3rd dose

Have you had or do you now have: (Please check)

Yes No

General/constitutional

18 My health is generally good

19 Recent weight gain/loss (>10lbs) in the past year

20 Night sweats/Hot flashes

21 Q Breast or Ovarian Cancer: if yes where/when: _____________

22 Other Cancer: if yes where/when: _______________________

23 Q Lobular carcinoma in situ (LCIS) or atypical hyperplasia of breast

24 Q Chest radiation for treatment of disease

25 Genetic condition or birth defect

26 Eye problems (except glasses or contacts)

27 Hearing problems

28 Frequent nosebleeds

29 Frequent sore throat

Cardio-respiratory

30 Mitral valve prolapse

31 Heart murmur

32 Varicose veins

33 Blood clots (head/leg/lungs)

34 Stroke or stroke-like problems

35 High blood pressure

36 High cholesterol

37 Chronic cough or other breathing problems/asthma

38 Tuberculosis (TB) or exposure to TB

Gastrointestinal

39 Stomach or bowel problems

40 Liver problems (hepatitis or tumor, etc.)

41 Gallbladder problems

PATIENT LABEL

Yes No

Genitourinary

42 Bladder, urine leaks or kidney problems

43 Uterine fibroids

44 Ovarian cysts

45 Breast lump or nipple discharge

46 Abnormal vaginal discharge/itch/odor

47 Endometriosis

48 Pain or bleeding with sex

Musculoskeletal

49 Arthritis

50 Osteoporosis

51 Other:____________________________________________

Skin

52 Acne

53 Tattoo

54 Piercing

55 Other Skin problem:__________________________________

Neurologic

56 Migraine headaches / aura (diagnosed by clinician)

57 Seizures/epilepsy

58 Numbness in arms/legs (recurring)

Psychological

59 Depression (serious / prolonged)

60 Have you ever considered suicide

61 Other psychological problem___________________________

Endocrine

62 Thyroid problems

63 Diabetes

Hematologic / Lymphatic

64 Anemia (Low iron)

65 Sickle cell disease/trait?

66 Blood clotting disorder

B. Hospitalization and surgeries: year and reasons

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

C. Accidents and Injuries: year and reasons

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

STAFF NOTES:

_____________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If you menstruate or have ever menstruated:

Age when period first started: _________

Day your most recent period began: ____/____/____

Was it normal? Yes No

Number of pads/tampons used on heaviest day?______________

Do you experience any of the following before or during your periods:

Cramps Bloating Bowel problems Emotional changes

Periods come every _______ days. Bleeding lasts ____ days.

Yes No

Are your periods usually regular?

Do you have bleeding between your periods?

Do you have bleeding after sex?

Are you taking hormones that are causing you to not menstruate?

If so, what? __________________________________________

Yes No

Have you ever been sexually active? If yes, please answer questions all questions in this section (complete both E-1 and E-2). If no, please skip to section E-2.

E-1 (if sexually active, please answer):

Age at first intercourse? _________

Kind of sex (please indicate all that apply): Oral sex? Anal sex?

Vaginal sex? Other:___________________________________

Gender of Sexual Partners (check all that apply):

Male Female Transgender Other:_____________________

Total number of lifetime partners:________

Number of partners in the past year:

___Male ___Female ___Transgender ___Other: _________________

Number of partners in the past 90 days:

___Male ___Female ___Transgender ___Other: _________________

Does your partner(s) have sex with (check all genders that apply):

Men Women Other_________________________________

Do you use a barrier method (e.g. condoms, dental dams):

Always Usually Sometimes Never

Were any of your partners:

An IV drug user Hemophiliac HIV positive

E-2 (if not sexually active please skip to here):

Do you have any questions/concerns about sex?

Have you ever had a Pap smear?

If yes: When was your last Pap smear? ___________________________

Have you ever had an abnormal Pap smear:

No Yes, date:___________result:___________________

Treatment to Cervix: LEEP/laser/cryotherapy/cone?

Do you perform monthly breast self-exams?

Have you ever had a mammogram? Most recent date: __________

Have you ever had the following? No If yes, check below:

HPV/Warts Herpes Trichomonas

Chlamydia HIV / AIDS Molluscum

Gonorrhea Syphilis Bacterial vaginosis (BV)

STAFF NOTES:

_____________________________________________________________________________________________________________________________________________________________________________________________

_______________________________________________________________

Do you want a birth control method today? Yes No

If yes, what method?_________________________________________

Check ALL Contraceptive Methods you have ever used:

Now Past Now Past

Pill (type)_____________ Diaphragm/Cervical cap

Depo Provera (shot) Tubal Ligation

Vaginal Ring (NuvaRing) Evra Patch

Condom Rhythm/Natural

Withdrawal Abstinence

Female condom Vasectomy

IUD (Brand used)____________ Foam/sponge/film

Other:__________________________________________________________

Comments/problems with method(s): _________________________________

_______________________________________________________________

Yes No

Could you be pregnant now?

Are you planning a pregnancy in the next year?

Have you ever had difficulty getting pregnant?

Have you ever been pregnant? If NO, skip to SOCIAL HISTORY

Age at first pregnancy _____ Total # of pregnancies? ________

Number of delivery(s) and Date(s) _________________________________

Number of C-section(s) and Date(s) ______________________________

Number of Miscarriage(s) and Date(s) ______________________________

Number of Abortion(s) and Date(s) ________________________________

Number of Ectopic(s) (tubal) and Date(s)_____________________________

Number of Living children ________________________________________

Have you had any of the following problems with a pregnancy?

High blood pressure Genetic or birth defects

Yes No

Do you drink alcohol? #______ drinks per week

Do you smoke? #_____ cigarettes per day

Do you have experience with drug abuse? What? _____________

Do you want information to get help for alcohol/drug use?

Have you received blood products prior to 1978?

Have you ever shared needles? (e.g. injecting drugs, tattooing, piercing)

Have you been hit, hurt or made to feel afraid by an intimate partner, now or in the past?

Have you experienced sexual abuse or coercion?

Are you experiencing emotional or relationship problems?

Are you experiencing financial or employment problems?

I acknowledge that the above information is correct & complete. I understand that if any reportable disease is found it will be reported to the Health Department.

Patient Signature _______________________________ Date ___________

This Health History information, as supplied by the patient, was reviewed & verified by:

Clinician

Signature_______________________________ (PA-C, CRNP, CNM, MD, DO)

Date __________

Clinician

Signature _______________________________ (PA-C, CRNP, CNM, MD, DO) Date __________

Clinician

Signature _______________________________ (PA-C, CRNP, CNM, MD, DO) Date __________

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A. REVIEW OF SYSTEMS

Patient Label

Patient Label

Patient Label

Patient Label

D. MENSTRUAL HISTORY

G. PREGNANCY HISTORY

E. GYN / SEXUAL HISTORY

F. CONTRACEPTIVE HISTORY

H. SOCIAL HISTORY / HEALTH HABITS

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