Established Patient Yearly Update Health History Form

Established Patient Yearly Update Health History Form

If nothing has changed in the specified categories below, write N/A.
Name

First NameLast Name
Date

MonthDayYear
Date
Reason for Visit
Age blanks Date of Birth blank
Primary Care Provider
Marital Status
Past Medical History
Any new medical issues that have developed since your last visit? Examples: asthma, blood clots, cancer, high blood pressure, high cholesterol, heart disease, diabetes, thyroid disease, osteoporosis, etc.
GYNECOLOGIC/OBSTETRIC HISTORY: Any new OB/GYN issues since you were last in? Examples: frequent UTI's, herpes, chlamydia, other STDs, incontinence, infertility, pregnancies, changes in bleeding, etc.
Have you received any vaccinations since your last visit?
SURGICAL HISTORY: Write date and type of any new surgeries.
Current medications and supplements (with dosing and instructions)
Medications you are allergic to:
Latex

YN
Eggs

YN
Iodine

YN
FAMILY MEDICAL HISTORY:
Have any family members developed any illnesses or cancer since your last visit? If yes, who and what type?
BASIC OB/GYN INFORMATION:
First day of last period blanks Last mammogram blank
Last Colonoscopy Last DEXA
Are you planning a pregnancy in the next year?
If applicable, what are you using for birth control?
Do you have any questions/concerns about your sexual life?
PERSONAL HEALTH HISTORY:
Occupation
What do you do for exercise?
Have you ever been physically, emotionally, or sexually abused?
Do you drink alcohol?

YN
Amount: Daily: blanks
Weekly:blankMonthly:
Do you use tobacco?

FormerNeverCurrent
Amount used:
Sandpoint Women's Health

Established Patient Yearly Update Health History Form (page 2)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Review of Systems - Please check any symptoms that have troubled you during the last several weeks.
General

FatigueUnexplained weight lossUnexplained weight gain
Eyes

Vision problems
ENT

Sore ThroatHeadacheSinus CongestionNasal dischargeEar Ache
Cardiovascular

Chest painHeart palpitations/fluttersSwelling in feet
Respiratory

CoughCoughing up bloodShortness of breathWheezing
GI

NauseaDiarrheaRectal bleedingAbdominal painVomitingConstipationBlack, tarry stoolsHeartburnBloatingHemorrhoids
GU

Blood in urineHeavy PeriodsVaginal dischargePainful urinationBleeding between periodsPelvic painLeaking of urineBleeding with intercourse
M-S

Muscle AchesJoint aches
Skin/Breast

Skin rashesBreast painBreast discharge
Neurologic

HeadacheFaintingSeizuresWeaknessNumbness
Psychiatric

DepressionAnxiety
Endocrine

Heat intoleranceNight sweatsCold intoleranceHot flashes
Heme/Lymph

Easy bruisingSwollen glands
Immune/Allergy

Seasonal allergiesFeversChills
Check here if none of the above apply.

None
Should be Empty:

Established Patient Yearly Update Health History Form

Past Medical History

FAMILY MEDICAL HISTORY:

BASIC OB/GYN INFORMATION:

PERSONAL HEALTH HISTORY:

Sandpoint Women's Health

Review of Systems - Please check any symptoms that have troubled you during the last several weeks.