FAMILY TREE CLINIC HEALTH HISTORY FORM

Health History Form
Preferred name:
Gender pronouns *
Legal Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Age: *
Gender Identity: *
Sex assigned at birth *

Female Male
Occupation:
Allergies:
Reaction(s):
Medications (including over the counter medications, birth control methods, herbs, supplements and vitamins):
Medication:
Dosage:
Medication:
Dosage:
Medication:
Dosage:
Medication:
Dosage:
Medication:
Dosage:
Medication:
Dosage:
PERSONAL MEDICAL HISTORY
Check if you have had any of the following:

Anemia Anxiety Hypertension high blood pressure Arthritis Asthma Blood clots or disorders Cancer Coronary artery disease(heart disease or heart attack) Depression Diabetes Elevated (high) cholesterol Gallbladder disease GERD (reflux/heartburn) Headache, migraines Hepatitis/Liver Disease Irritable bowel disease Osteoporosis Renal (kidney) disease Seizure disorder Stroke Thyroid disease Breast lump Eating disorder Chemical dependency Urinary tract/bladder infection (UTI)
Other - please list:
Have you ever had surgery?

Yes No
Have you ever had surgery? *

Yes No
If yes, please explain:
Have you ever been hospitalized?

Yes No
Have you ever been hospitalized? *

Yes No
If yes, please explain:
GENERAL HEALTH
Do you smoke or use tobacco?

Yes No
Do you smoke or use tobacco? *

Yes No
If yes, how much per day?
Are you interested in quitting?

Yes No
Do you use e-cigarettes/vaping?

Yes No
Do you drink alcohol?

Yes No
Do you drink alcohol? *

Yes No
If yes, how many drinks per week?
Do you use recreational/street drugs?

Yes No
If yes, how often per week?
Have you ever used needles to take drugs?

Yes No
Have you ever used needles to take drugs?

Yes No
If yes, do you share needles?

Yes No
How often do you exercise?
Are you being or have you been sexually or physically mistreated?

Yes No
Do you want to talk about it?

Yes No

Did you receive the following immunizations/vaccines: *

Yes

Hepatitis B

HPV (Gardasil)

Tdap (Tetanus/diptheria/pertussis)

Is there anything else you would like us to know about you or your health?
FAMILY MEDICAL HISTORY
If you are adopted check here If you do not know any biological family medical history check here

Mark for any relatives with the following

Mother

Father

Brother

Sister

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Blood Disease/Blood Clots

Cancer

Cardiovascular (heart) Disease

Diabetes

Genetic Disease

Hypertension (high blood pressure)

Osteoporosis

Stroke

Thyroid Disease

Other (please list)
Sexual Health and Family Planning
Do you or your partner(s) want to be pregnant?

Now In the future Never Unsure
Are you or your partner(s) currently using a method of birth control?

Yes No
If yes, what method?
How long have you used this method?
Any problems with this method?
Check which methods of Birth Control you have ever used:

Birth Control Pills The Patch Vaginal Ring (Nuva Ring) Spermicide Depo (The Shot) Diaphragm Norplant Implanon/Nexplanon IUD Tubal ligation Condoms Cervical cap Fertility awareness Cycle beads Withdrawal (Pull-out) Vasectomy
Check any of the following you currently have, or have had in the past:

Chlamydia Gonorrhea Herpes HIV Genital Warts/HPV Hepatitis B or C Syphilis Pelvic Inflammatory Disease (PID) Trichomonas
Have you ever been sexually active? *

Yes No
Are you currently sexually active? *

Yes No
What are the gender(s) of your sexual partner(s)?
How many people have you had sex with in the past 3 months? *
How many people have you had sex with in the past 12 months? *
What types of sexual activities do you practice?

Vaginal Oral Anal Touch with hands Sex toys
What do you do to prevent sexually transmitted infections (STIs)?
What do you do to prevent sexually transmitted infections (STIs)? *

0/100
GYNECOLOGICAL AND BREAST HISTORY
Have you ever had a Pap smear? *

Yes No
When was your last Pap smear?
Have you ever had an abnormal Pap? *

Yes No
If yes, please explain:
MENSTRUAL CYCLE
When did your last period start?
Was it normal?
Periods come every ________ days
fill in the blank
and last _________ days
fill in the blank
Periods are usually

light moderate heavy crampy irregular
Age periods started
PREGNANCY HISTORY
Are you pregnant now? *

Yes No Unsure
Have you ever been pregnant? *

Yes No
How many times?
# of live births
date(s)

Month Day Year
Date
# of abortions
date(s)

Month Day Year
Date
# of miscarriages,
date(s)

Month Day Year
Date
# of ectopic
date(s)

Month Day Year
Date
Any problems with pregnancy or birth?

Yes No
If yes, please explain
Diabetes in pregnancy?

Yes No
For Ages 40 and Over
Have you ever had a mammogram?

Yes No
Was it normal?

Yes No
If no, please explain:
Check if you have had any of the following:

Hot flashes Trouble sleeping Night sweats Rapid mood changes Vaginal dryness Libido problems Urine leaking
Family Tree Clinic ● 1619 Dayton Avenue, St. Paul, MN 55104 ● (651) 645-0478
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Health History Form