OBGYN Clermont FL - Gynecologist Clermont FL - South Lake ...



MEDICAL HISTORYName: ___________________________________________ Age: _________ Date: ______________E-mail address: ____________________________________________________________________ Name of Primary Physician: _________________________________ Date last seen: ________________Are you (or could you) be pregnant at this time? Yes NoDo you have a latex allergy? Yes NoDo you have an Advanced Directive (regarding medical care in case you are incapacitated?) Yes No DRUG ALLERGIES:1. _______________________ 2. ______________________ 3. _____________________ CURRENT MEDICATIONS: (list medications, dosages, & frequency)1. ______________________ 2. ______________________ 3. ______________________ 4. ______________________ 5. ______________________ 6. ______________________ 7. ______________________ 8. ______________________ 9. ______________________VITAMIN OR HERB SUPPLEMENTS: (list medications, dosages, & frequency)1. ______________________ 2. ______________________ 3. ______________________ 4. ______________________ 5. ______________________ 6. ______________________ VACCINATION HISTORY: (please circle all that apply)Have you had all your childhood vaccines? Yes No Tetanus in the past 10 years? Yes NoHepatitis B Vaccine? Yes No Flu shot this year? Yes No Pneumococcal Vaccine? Yes NoPREVENTATIVE MEDICINE HISTORY: Date of Last (if any) (circle below) ______ Please explain abnormal results below_Last Pap __________ Normal Abnormal _______________________________Mammogram __________ Normal Abnormal _______________________________Bone Density Test __________ Normal Abnormal _______________________________Colonoscopy __________ Normal Abnormal _______________________________Barium Scan __________ Normal Abnormal _______________________________Stool test for blood __________ Normal Abnormal _______________________________Cholesterol Test __________ Normal Abnormal _______________________________Thyroid Test __________ Normal Abnormal _______________________________PAST OBSTETRICAL HISTORY: (indicate number)Total times pregnant including miscarriages: ___ FULL term deliveries (37 weeks pregnant or beyond) ____Pre-term deliveries (less than 37 weeks) ____Miscarriages and abortions ___ Number of living children ___Pregnancy complications: NONE (please check all that apply)Baby died near term: ____Cord Prolapse: ____Ectopic Pregnancy: ____1st trimester Bleeding: ____Gestational Diabetes: ____HELLP Syndrome: ____Infertility: ____Incompetent Cervix: ____Growth Retardation: ____Placenta Abruption: ____Placenta Previa: ____Pre-Eclampsia: ____Premature rupture of membranes at ______ weeksPre-term labor at ______ weeksShoulder Dystocia: ____Recurrent Miscarriages____Twins/Multiple babies: ____Other: ___________________________________________________________________________________MENSTRUAL: (please circle all that apply)Age at first period? _____Date of last period? _____ Cycles are/were? Regular IrregularMenses flow? Light Moderate HeavyTypically last _____ number of days Symptoms include: Bloating Breast tenderness Mood swings Abdominal pain/cramps Other: ________________Do you have a history of any of the following? (please circle all that apply) Abnormal Pap Smear/sAdenomyosis Breast DiseaseChronic Pelvic PainEndometriosisFibroidsExposure to DESUrinary IncontinenceOvarian CystPelvic AdhesionsPelvic Inflammatory DiseasePolycystic OvaryUterine ProlapseCervical CancerEndometrial CancerOvarian CancerOther: ____________Please explain: _____________________________________POSTMENOPAUSAL WOMEN ONLY: (please check all that apply)Night Sweats _____Hot Flashes # _____ times per dayPain with Intercourse _____Vaginal Dryness _____Mood Liability_____Bone Pain _____Length of time experiencing these symptoms # _________ months/years (circle one) Other: ______________________SEXUAL HISTORY: (please circle all that apply)Birth control currently being used: NONE Condoms Diaphragm IUD Pills Injection Vasectomy Other: _____________Sexual preference? Heterosexual Homosexual Are you currently sexually active? Yes No# lifetime sexual partners? More/Less than 5 Age first had intercourse? More/Less than 16 years oldLevel of sexual interest? Healthy Decreased AbsentHave you ever been diagnosed with any of the following? (please check all that apply)Chlamydia ___ Gonorrhea ____ Trichomonas ____ Syphillis ____ HIV ____ HPV/Genital Warts ____ Herpes ____ Please tell us the date and if you were treated: ___________________________________________________PAST MEDICAL HISTORY: (please circle all that apply)Alcoholism Anemia AsthmaArthritis Atrial FibrillDeep Vein ThrombosisBleeding Tendency Crohn’s/Colitiss Colon PolypsDepression DiabetesHeart AttackEmphysema Epilepsy GlaucomaGoiter Hay FeverHigh Blood PressureHepatitis (B or C) Heartburn Heart FailureHyperthyroid HypothyroidMitral Value ProlapseKidney Disease Leukemia Liver DiseaseMental Illness MigraineTuberculosisNervous Breakdown Obesity PneumoniaRheumatism StrokeOther Cancer: _________Ulcers Breast Cancer Cervical CancerColon Cancer Ovarian CancerOther Condition: _______FAMILY HISTORY: (please list disease for each member)Paternal Grandmother: _______________________Maternal Grandmother: ________________________Paternal Grandfather:__________________________Maternal Grandfather: _________________________Father: __________________________________Mother: ___________________________________Uncles: __________________________________Aunts: ____________________________________Brothers: _________________________________Sisters: ____________________________________PAST SURGICAL HISTORY: (please circle all that apply AND indicate the year it occurred)Appendix ____Breast Biopsy ____Hernia ____Kidney ____Tonsils____Cervical Biopsy ____D&C ____Endometrial Biopsy ____Hysterectomy ____Hystosalpingogram ____Tubal Ligation ____Laparoscopy ____Mastectomy ____Ovary(ies) Rt or Lft ____Other: _________________________________PAST PROCEDURE HISTORY: Test Body RegionResultsUltrasound of ______________________________________________________________________CT Scan of ______________________________________________________________________MRI of ______________________________________________________________________PERONAL INFORMATION:Current Occupation: ___________________________ Marital Status: Married Single Divorced WidowedCurrent aerobic exercise program? Yes No How many days a week do you exercise? _____Alcohol use? Yes NoIf yes, how many drinks per day? _____Have you ever smoked? Yes No Do you smoke now? Yes No Packs per day? ____ How many years? ____Do you take any illicit street drugs? Yes No If yes, which? ________________________________________Do you drink caffeinated products (soda, coffee, tea, energy drinks)? Yes No If yes, how many cups per day? ____SYMPTOMS: (check symptoms you currently have)GeneralHead, Eyes, Ears, Nose, ThroatLungsBreast__ Fever__Head Injury__Labored Breathing__ Rashes__Chills__Visual Changes__Coughing up Blood__ Lumps__ Appetite Change__ Eye Pain__ Productive Cough__ Tenderness__ Dehydration__ Sinus Congestion/Drainage__ Congestion__ Skin Lesions__ Mental Status Changes__ Hearing Changes__ Dimpling__Acute Diseases__ Neck MassGastrointestinal__ Nipple Changes__ Neck Pain__ Abdominal Pain__ Nipple DischargeGenital__ Throat Drainage__ Abdominal Masses__Pain__ Throat Pain__ HeartburnMusculoskeletal__ Masses/Growths__ Oral Ulcers__ Nausea__ Muscle Aches__ Abnormal Bleeding__ Hoarseness__ Vomiting__ Weakness__ Abnormal Discharge__ Diarrhea__ Fatigue__Pain w/IntercourseIntegumentary/Skin_Constipation__ Arthritis__ Pain w/Menstrual Cycle__ Rashes__Blood in Stool__ Osteoporosis __ Rashes__ Masses__ Tarry Stool__ Difficulty w/Balance__ Unusual Skin Lesions__ Vomiting Blood__ Recent Fracture(s)Neurological__ Itching__ Changes in bowel habits__ Seizures__ Hives__ BloatingEndocrine__ Speech Changes__ Scars__ Excess Hunger__Diabetes__ Loss of Sensation__ Scars that won’t heal__ Gas__ Temperature Change__ Loss of Movement__ Hemorrhoids__Weight ChangeImmunologic__ Polyps__ Hot FlashesHematological__ Immunosuppression__ Rectal Bleeding__ Easy Bruising__Severe Allergies__ Ulcers__ Bleeding Disorder__ Clotting DisorderUrinaryPsychiatric__ Pain w/Urination__DepressionHeart__ Blood in Urine__ Suicidal Intentions__ High Blood Pressure__ Frequent Nighttime Urination__ Homicidal Intentions__ Palpitations__ Chronic UTIs__ Anxiety__ Chest Pain/Angina__ Incontinence__ Known Psychiatric Disorders__ Edema in Arms/Legs__ Rapid Heartbeat__ Irregular Heartbeat__ High CholesterolOther symptoms not listed: ________________________________________________________________________________________I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his staff responsible for any errors or omissions that I have made in the completion of this form.Patient’s Signature: ___________________________________________________ Date: _______________ ................
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