WOMEN’S HEALTH



Initial History

JULIA

NAME________________________________DOB_____________AGE______Date_____________

Phone#: cell_____________________home__________________work__________________

Emergency contact: Name___________________Phone#__________________Relationship________

Allergies: ___________________________________________________

(Medication Latex Surgical Steel Foods Other)

Current Medications:_______________________________________________________________

Immunizations : are you up to date? Tdap: N Y Varicella: N Y Hep B: N Y;

MMR: N Y HPV vaccine: N Y Did you get all 3 shots? ______________

Are you planning a pregnancy within the next year? N Y

Current method of birth control __________________ How long have you used it______________

Any problems _________________________________________________________________________

Would you like to be using birth control N Y what kind?________________________________

Age when your periods began___________ Age when you first had intercourse__________

First day of last normal period___________ How many days do you bleed_______________

How often do you get your period________ Are your periods light___medium___heavy___

Date of last pap smear__________________results_______________________________________

History of abnormal pap N Y Date___________, Provider office: ______________________

Number of times pregnant________live births________miscarriages________abortions_______

Problems/complications of pregnancy_________________________________________________

Children’s age and birthweight_______________________________________________________

Smoker: N Y Amount per day________________________________________________

Alcohol/Drugs: N Y Amount per day________________________________________________

Do you have Vaginal sex? Anal sex? Oral sex?

Do you have sex with men? women? both?

Have you had a blood transfusion before 1985? N Y

Have you had more than three(3) partners in the last six(6) months N Y

Have you been diagnosed with a sexually transmitted disease in the past three(3) years? N Y

Has your partner been diagnosed with a sexually transmitted disease? N Y

Do you think your partner may have a sexually transmitted disease? N Y

Have you or your partner used IV drugs? N Y

Have you or your partner been incarcerated in the past (12) months? N Y

Have you experienced unwanted sexual touch, verbal or physical violence and/or threats? N Y

Are you afraid anyone might hurt you? N Y

Do YOU now have or have YOU ever had?

Known STDs N Y____________________________

PID/infection uterus/ tubes/ ovaries N Y____________________________

Uterine growths/fibroids/abnormality N Y____________________________

Pain/bleeding with intercourse N Y____________________________

Heart Disease/murmur N Y____________________________

Sickle Cell N Y ___________________________

|Stroke |N |Y ___________________________ |

|High blood pressure |N |Y____________________________ |

|High cholesterol/fats |N |Y____________________________ |

|Blood clots/varicose veins |N |Y____________________________ |

|Lung disease/asthma |N |Y____________________________ |

|Cancer |N |Y____________________________ |

|Colorectal cancer or polyps |N |Y____________________________ |

|Change in bowel habits |N |Y____________________________ |

|Thyroid problems |N |Y____________________________ |

|Breast disease/lump/discharge |N |Y____________________________ |

|Diabetes |N |Y____________________________ |

|Iron Deficiency Anemia |N |Y____________________________ |

|Frequent or severe headaches |N |Y____________________________ |

|Seizures/fainting spells |N |Y____________________________ |

|Emotional problems/depression |N |Y____________________________ |

|Vision problems |N |Y____________________________ |

|Chest pain/difficulty breathing |N |Y____________________________ |

|Stomach/intestinal problems |N |Y____________________________ |

|Gall bladder/liver problems |N |Y____________________________ |

|Kidney/bladder infections/problems |N |Y____________________________ |

|Hepatitis |N |Y____________________________ |

|Skin disorders |N |Y____________________________ |

|Do you have any medical conditions which may weaken your immune |N |Y____________________________ |

|system? (i.e. chemo, HIV, immunoglobulin disorder, steroid therapy, | | |

|transplant medications). | | |

|Surgeries and medical procedures (dates, types):_____________________________________ |

|____________________________________________________________________________ |

Have your parents, brothers, or sisters ever had?

|Heart disease |N |Y____________________________ |

|Stroke/heart attack before age 50 |N |Y____________________________ |

|High blood pressure |N |Y____________________________ |

|High cholesterol/fats |N |Y____________________________ |

|Diabetes |N |Y____________________________ |

|Cancer |N |Y____________________________ |

|Colorectal cancer or polyps |N |Y____________________________ |

|Genetic problems(i.e.muscular dystrophy) |N |Y____________________________ |

|Kidney disease |N |Y____________________________ |

|Mother used DES to prevent miscarriage |N |Y____________________________ |

|Other |N |Y____________________________ |

Client Signature_________________________________________Date________________

Staff Signature__________________________________________Date________________

Interpreter Signature____________________________________Date_________________

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