Patient History
Patient Information
First Name
*
MI
Last Name
*
Date of Birth
Marital Status
Married
Single
Divorced
Widowed
Occupation
Education
History of
Tobacco Use
Current Amount
Years of Use
Alcohol Use
Current Amount
Drug Use
Current Type and Amount
Obstetrical History
No. of Pregnancies
Premature Births < 37 wks.
Miscarriages
Abortions
Ectopic
Living Children
Born (mo/yr)
/
Weight (lbs/oz)
/
Weeks Pregnant
Sex
M
F
Delivery Type
Vag
C-Sec
Remarks
Born (mo/yr)
/
Weight (lbs/oz)
/
Weeks Pregnant
Sex
M
F
Delivery Type
Vag
C-Sec
Remarks
Born (mo/yr)
/
Weight (lbs/oz)
/
Weeks Pregnant
Sex
M
F
Delivery Type
Vag
C-Sec
Remarks
Born (mo/yr)
/
Weight (lbs/oz)
/
Weeks Pregnant
Sex
M
F
Delivery Type
Vag
C-Sec
Remarks
Born (mo/yr)
/
Weight (lbs/oz)
/
Weeks Pregnant
Sex
M
F
Delivery Type
Vag
C-Sec
Remarks
Born (mo/yr)
/
Weight (lbs/oz)
/
Weeks Pregnant
Sex
M
F
Delivery Type
Vag
C-Sec
Remarks
Gynecological History
Menstrual History
Age at First Period
Age at Menopause
Regular Periods
Yes
No
Comments
Vaginal Infection / Sexually Transmitted Infection History:
Please check if you have ever had any of the following:
Chronic Yeast Infections
Trichomonas
Chronic Bacterial Vaginosis
Chlamydia
Herpes
Gonorrhea
Syphilis
Pelvic Inflammatory Disease
Human Papilloma Virus (HPV, Warts)
Other
(If you find any of the Sexual History questions particularly offensive, leave blank and discuss with your Provider)
Sexual History
Have you ever had sex?
Yes
No
Age at first sexual experience
Number of lifetime partners
Are you currently sexually active?
Yes
No
Do you have sex with
Males
Females
Both
Contraceptive History
Current method
Other methods you have used
Pap Smear History
Date of last Pap Smear
Any history of abnormal Pap?
Yes
No
Please list any treatments you have had for abnormal Paps
Past Medical History
Please check if you have had any of the following conditions
1. Migraines
w/Aura (Neurologic Changes)
2. Heart Disease/Problems
Type
3. High Blood Pressure
4. High Cholesterol
5. Respiratory (Lung) Disease/Problems
Type
6. Asthma
7. Breast Disease/Problems
Type
8. GERD/Reflux
9. Stomach Ulcers
10. Bowel Disease/Problems
Type
11. Kidney Disease/Problems
Type
12. Urinary Incontinence
13. Recurrent/Frequent Urinary Infections
14. Blood Disorders
Type
15. Blood Transfusions
16. Blood Clots - DVT, PE
17. Skin Disease/Problems
Type
18. Thyroid Disorder - Hypothyroidism
Thyroid Disorder - Hyperthyroidism
19. Diabetes
Gestational Diabetes
20. Cancer
Type
Type
21. Epilepsy/Seizures
22. Neurological Disorders/Problems
Type
23. Arthritis
24. Osteoporosis
25. Autoimmune Disease/Problems
Type
26. Endometriosis
27. Fibroids of Uterus
28. Infertility
29. Uterine/Cervical Abnormality
Type
30. Anxiety
31. Depression
32. Abuse/Domestic Violence
33. Other
Describe
Describe
Surgical History
Hospital Admissions/Surgeries (date/reason)
Family History
Please state if each family member is living or deceased, current age or age at death, any major medical problems or cause of death.
Mother
Living
- Age
Deceased
- Age
Cause of Death
Medical Problems
Father
Living
- Age
Deceased
- Age
Cause of Death
Medical Problems
Mother’s Mother
Living
- Age
Deceased
- Age
Cause of Death
Medical Problems
Mother’s Father
Living
- Age
Deceased
- Age
Cause of Death
Medical Problems
Father’s Mother
Living
- Age
Deceased
- Age
Cause of Death
Medical Problems
Father’s Father
Living
- Age
Deceased
- Age
Cause of Death
Medical Problems
Siblings
Living
- Age
Deceased
- Age
Cause of Death
Medical Problems
Siblings
Living
- Age
Deceased
- Age
Cause of Death
Medical Problems
Siblings
Living
- Age
Deceased
- Age
Cause of Death
Medical Problems
Siblings
Living
- Age
Deceased
- Age
Cause of Death
Medical Problems
Children
Living
- Age
Deceased
- Age
Cause of Death
Medical Problems
Children
Living
- Age
Deceased
- Age
Cause of Death
Medical Problems
Children
Living
- Age
Deceased
- Age
Cause of Death
Medical Problems
Children
Living
- Age
Deceased
- Age
Cause of Death
Medical Problems
Children
Living
- Age
Deceased
- Age
Cause of Death
Medical Problems
Please list known close blood relatives with any of the following problems.
Breast Cancer
Ovarian Cancer
Endometrial/Uterine Cancer
Colon Cancer
High Blood Pressure
High Cholesterol
Heart Disease/Heart Attack
Osteoporosis
Blood Disorders/Bleeding Problems
Diabetes
Twins or Triplets
Congenital, Genetic or Birth Defects
Patient Signature
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Date