Dr. Marissa Largoza Dr. Rene Saenger



Patient Health HistoryToday’s Date: ________________________ Appointment Date: ___________________Name__________________________________________________________ DOB: ___/____/____ Reason for today’s visit (Please list ALL symptoms):______________________________________ 4.___________________________________________________________________________________ 5.___________________________________________________________________________________ 6._____________________________________________Past Medical HistoryPlease list any illness you had or have been diagnosed with by a physician:List: ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________Preventative Health MaintenanceDate of last pap smear? ________________ Was your last pap smear normal? Yes No [If done elsewhere please bring copy of results] Date of last Colonoscopy? ______________Was your last colonoscopy normal? Yes No 3.) Date of Last Bone Density Test? ___________ Was your Bone Density normal? Yes No Date of last Pelvic Ultrasound? ____________Was your last Pelvic Ultrasound normal? Yes No 5.) Date of last mammogram? __________ Was your mammogram normal? Yes No Past Surgical History OR Major Injuries: List ANY surgeries you have ever had!Date and Surgery: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 6.) Do you perform regular Self Breast Exams? Yes No 7.) Date of last breast biopsy? _____________ Was your last biopsy normal? Yes No _________________________________________________________________________________________________________MedicationsPlease list all current medications prescribed by our doctors!Medication Reason for Medication Dose & Frequency *If using Generic medication please list the name as indicated on your prescription bottle._________________________________________________________________________________________________________________________________________________________________________________________________________________________________List any prescriptions given by ANY other doctor:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________Allergies NO KNOWN DRUG ALLERGIESAre you allergic to any medications?Please list medication and reaction:________________________________________________________________________________________________________________________________FoodIndicate food and reaction: __________________________________________________________________EnvironmentalIndicate and reaction: ________________________________________________________________When was your last Vaccine / Immunization:Flu Shot: ______________________________Pneumonia Vaccine: ____________________Shingles Vaccine: _______________________Gardasil: ______________________________Family HistoryWhat has anyone in your immediate family (mother/father/siblings/grandparents) been diagnosed with: Illness? _____________ who? ______________________________ age? __________ Maternal / Paternal Illness? _____________ who? ______________________________ age? __________ Maternal / Paternal Illness? _____________ who? ______________________________ age? __________ Maternal / Paternal Illness? _____________ who? ______________________________ age? __________ Maternal / Paternal Illness? _____________ who? ______________________________ age? __________ Maternal / Paternal Illness? _____________ who? ______________________________ age? __________ Maternal / Paternal Illness? _____________ who? ______________________________ age? __________ Maternal / Paternal Illness? _____________ who? ______________________________ age? __________ Maternal / Paternal Illness? _____________ who? ______________________________ age? __________ Maternal / Paternal Illness? _____________ who? ______________________________ age? __________ Maternal / Paternal Illness? _____________ who? ______________________________ age? __________ Maternal / Paternal Illness? _____________ who? ______________________________ age? __________ Maternal / Paternal Illness? _____________ who? ______________________________ age? __________ Maternal / Paternal Illness? _____________ who? ______________________________ age? __________ Maternal / Paternal Illness? _____________ who? ______________________________ age? __________ Maternal / Paternal Illness? _____________ what? _____________________________ age? __________ Maternal / PaternalSocial HistoryAlcohol Use Every Day Some Days Former Never Amount Used: _____ Age Start: _____ Age Stop: ______Substance Drug Use Yes Describe: ___________________________________________________________________Tobacco Use Every Day Some Days Former Never Amount Used: _____ Age Start: _____ Age Stop: ______Marital Status Dating Divorced Engaged Married Not dating Remarried Single Separated WidowedEmployment (Occupation) __________________________ Unemployed Homemaker Student RetiredExerciseRegular Heavy Moderate Minimal Active Competitive Athlete SedentaryDaily Diet Describe: _____________________________________________________________________________Any Other Problems______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Your Education Level: ______________________ Your Occupation: ___________________Your Infection Risk/Exposure:____________ Your Hazardous Exposure: ___________Any military history? Y / N What branch? __________________________________________Any domestic violence to report? _________________________________________________Reproductive History(Answer ALL questions)MenstrualAge Period Began: ______Length of periods: ______ # daysNumber of days between periods: ______Last Menstrual Period (Date): __________________Menopause Status (pre/peri/post): ______________Method of Birth Control (pills, tubal, vasectomy etc.): _________________________________________Do you ever have bleeding in between periods? Yes/NoAverage Flow: heavy medium lightCertainty of LMP Date: Y or N _________Menopause: Y / N Age: _____Clots(Y/N)? : _________On Hormone Replacement Therapy (Y/N)? : ______PregnanciesList ALL pregnancies including terminations and miscarriagesTotal PregnanciesFull TermPrematureAb Induced(abortion)AbSpontaneous (miscarriage)EctopicsMultipleLiving########Please list all deliveriesD.O.B. Sex of child Birth Wt # weeks at delivery Hrs in labor Type of delivery* Anesthesia** Complications****Types of deliveries= Vaginal, c-section, forceps, vacuum OR v-bac** Types of Anesthesia= Epidural, general, spinal, IV medications OR none***Complications= List any problems or issues during pregnancy and at delivery________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(PatientHealthHistory_REV_9/2014) ................
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