Medical history information sheet



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MEDICAL HISTORY INFORMATION SHEET



Name__________________________
Any concerns/issues you would like to discuss today?

GYNECOLOGY HISTORY G___P_____


First day of last menstrual period?




Age at 1st period




# of days between periods

(from 1st day of period to 1st day of next period)






Length of period (# of days of bleeding)




Heavy bleeding?

Y / N

Cramps?

Y / N




Birth control method  N/A




Number of sexual partners in last year




Are you currently sexually active?

Y / N

Have you had any sexually transmitted diseases? If yes, which ones?

Y / N

Would you like to be tested today?

Y / N




When was your last pap smear?




Any history of abnormal pap smears?

When was this?

What treatment was performed?


Y / N



When was your last mammogram?  N/A




Any history of abnormal mammograms?

Y / N

Do you do self-breast exams?

Y / N




Any history of sexual abuse or domestic violence?

Y / N

Would you like to talk about this today?

Y / N


If you are in menopause:

When did this begin?




Which hormone replacement therapy are you taking?  N/A




What symptoms are you having? Please circle

Hot flashes Vaginal dryness Night sweats

Vaginal bleeding Low libido Insomnia

Mood changes




OBSTETRIC HISTORY- No changes

List all previous pregnancies


PAST MEDICAL HISTORY - No changes


List all medical problems

PAST SURGICAL HISTORY- No changes


List all previous surgeries

Primary Care Doctor:

_______________________________________



Please bring this information sheet with you when you arrive for your appointment.
Today's date________________

Age_______ Date of birth________________



MEDICATIONS


List all medications, herbs or supplements

ALLERGIES to any medicines


SOCIAL HISTORY- Do you do any of the following:


Marital status







Smoke?

Y / N

How many packs a day?




Drink alcohol?

Y / N

How many drinks a week?




Do drugs?

Y / N

Which drugs?




Do you exercise?

Y / N

What kind and how often?




Use sunscreen?

Y / N







Use a seatbelt?

Y / N







Calcium in your diet?

Y / N







Had the HPV vaccine? (if you are 26 or younger)

Y / N

If not, would you like this?

Y / N



FAMILY HISTORY-Please circle if you have any family members with the following:


Breast cancer Uterine cancer Ovarian caner

Colon cancer Stroke High blood pressure

Heart disease Blood clots Diabetes

Osteoporosis Birth defects Other:



PREVENTATIVE

Have you had the following test? When was this test last done?


Cholesterol (45 y/o, q5y)




Diabetes (45y/o, q3y)




Thyroid




Colonoscopy (50y/o, q10y)




Bone density



REVIEW OF SYSTEMS- Please circle if you have any of the  NONE OF THE BELOW following

Fever Fatigue Hair loss

Chest pain Cough Shortness of breath

Palpitations Feeling hot/cold

Breast pain Breast lump Nipple discharge

Diarrhea Constipation Blood in stools

Pain with urination Frequent urination

Urge to urinate Blood in urine



Loss of urine/incontinence Change in height

Cuts that don't stop bleeding Weight loss/gain


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