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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