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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 __________
-----------------------
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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