AWH HEALTH HISTORY QUESTIONNAIRE

HEALTH HISTORY QUESTIONNAIRE
Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Reason For Visit
Primary Care Physician
Preferred Pharmacy 1
City
Pharmacy 1 Location
Preferred Pharmacy 2
City
Pharmacy 2 Location
Age when you started having periods
Date of Last Menstrual Period

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Number of pregnancies
Full term deliveries
Pre term deliveries
Miscarriage / Abortions
Living Children
Are you currently pregnant
Are you allergic to latex?

Please list Allergies (Medication or Enviromental)

Rows	Allergy	Reaction
1
2
3
4

Please include all over the counter and prescription medications

Rows	Medication	Dose / Strength	Number of Pills / amt	Times / Day
1
2
3
4
5
6
7
8
9

Medical History

Please Check if you have ever been diagnosed with any of the following conditions:
Select all that Apply

Other
If yes to Diabetes, please select type:
If yes to Hepititis, please select type
GYN PROBLEMS
Select all that Apply

Other
SURGICAL HISTORY

Have you ever had any of the following surgeries and if so, when?

Rows	Age	Year
Arthroscopy
Appendectomy
Cataracts
Cardiac Surgery
Cystoscopy
GallBladder Removed
Hip Replacement
Knee Replacement

Rows	Age	Year
Sinus Surgery
Tonsillectomy
Tonsillectomy/Adenoids
Tubes in Ears
Wisdom Tooth Extraction

List any other surgeries

Rows	Proceedure	Age	Year
1
2
3

GYN SURGICAL HISTORY

Have you ever had any of the following surgeries and if so, when?

Rows	Age	Year
Breast Augmentation
Breast Biopsy
Breast Reduction
Cesarean Section
Cervical Proceedure - Cone Biopsy
Cervical Proceedure - Cryp
Cervical Proceedure - LASER
Cervical Procedure - LEEP
Cervical Proceedure - Colposcopy
D & C
Endometrial Ablation
Hysteroscopy
Laparoscopy
Laparotomy
Tubal Ligation

Type a question

Rows	Type	Age	Year
Hysterectomy Type= Abd/Vag
Mastectomy Type= R / L / B
Ovaries Removed Type= R / L / B
Other
Other
Other

FAMILY MEDICAL HISTORY

Type a question

Rows	Mother	Father	Sister	Brother	Daughter	Son	Maternal Grandmother	Maternal Grandfather	Paternal Grandmother	Paternal GrandFather
Breast Cancer
Colon Cancer
Ovarian Cancer
Uterine Cancer
Diabetes
Hypertension
Stroke
Heart Disease
Thyroid Disease
Osteoporosis
Kidney Problems
Epilepsy
Lung Disease

OBSTETRICAL HISTORY
Pregnancy #1:
Type of Pregnancy:     . Delivery Date:   Date   Baby Name:   Type a label
Gestational Age      Weight:   Type a label   Sex:
Hospital: Type a label   Doctor:  Type a label
Complications
Pregnancy #2:
Type of Pregnancy:     . Delivery Date:   Date   Baby Name:   Type a label
Gestational Age      Weight:   Type a label   Sex:
Hospital: Type a label   Doctor:  Type a label
Complications
Pregnancy #3:
Type of Pregnancy:     . Delivery Date:   Date   Baby Name:   Type a label
Gestational Age      Weight:   Type a label   Sex:
Hospital: Type a label   Doctor:  Type a label
Complications
Pregnancy #4:
Type of Pregnancy:     . Delivery Date:   Date   Baby Name:   Type a label
Gestational Age      Weight:   Type a label   Sex:
Hospital: Type a label   Doctor:  Type a label
Complications
Pregnancy #5:
Type of Pregnancy:     . Delivery Date:   Date   Baby Name:   Type a label
Gestational Age      Weight:   Type a label   Sex:
Hospital: Type a label   Doctor:  Type a label
Complications
Pregnancy #6:
Type of Pregnancy:     . Delivery Date:   Date   Baby Name:   Type a label
Gestational Age      Weight:   Type a label   Sex:
Hospital: Type a label   Doctor:  Type a label
Complications
SOCIAL HISTORY
Race:

Other
Ethnicity:
Primary Language:

Other
Gender Assigned at Birth
Gender Identity:
Marital Status:
Occupation:
Place of Employment:
Diet:
Exercise:
Caffeine Intake:
Caffeine Drinks per day:
Tobacco Use No Yes Former*
Type: Type a label Amt/Day: Type a label Years: Type a label Years Quit: Type a label
Alcohol Use: No Yes Former
Frequency: Year Quit:
Illicit Drug Use: No Yes Former
Type: #Years: Number Years Quit:
HEALTH MAINTENANCE
Date of Last Pap Smear

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Result
Date of Last Mammogram

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Result
Date of Last Colonoscopy

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Result
Date of Last Bone Density

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Result
Date of Last Cholesterol Test

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Result
Chicken Pox Status:
Hepatitis B:
Gardasil Vaccine:
Date of Last Flu Vaccine

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Last Tetanus Vaccine

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Last Pneumonia Vaccine

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Last MMR Vaccine

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

HEALTH HISTORY QUESTIONNAIRE

Medical History

GYN PROBLEMS

SURGICAL HISTORY

GYN SURGICAL HISTORY

FAMILY MEDICAL HISTORY

OBSTETRICAL HISTORY

SOCIAL HISTORY

HEALTH MAINTENANCE