lifecareforwomen.com - Updated Patient Form

MEDICAL HISTORY FORM
NAME

First NameLast Name
DOB

MonthDayYear
Date
DATE

MonthDayYear
Date
SSN
I. What brings you to see the Doctor?
II. Menstrual History
First date of last menstrual period

MonthDayYear
Date
Age when 1st period started
Age at menopause
Hysterectomy

YesNo
Are you cycles regular?

YesNo
Are you periods:

RegularIrregular
How many days do you bleed?
How long are your cycles (average in 28-30 days)
How many days of heavy flow?
Do you need double protection?

YesNo
Do you have bleeding between periods?

YesNo
Are you periods painful?

YesNo
How many days of pain per cycle?
III. Obstetrical History:
Total number of pregnancies?
Miscarriages
Elective terminations
Living Children
IV. Gynecologic History
Date of last pap smear

MonthDayYear
Date
Have you ever had an abnormal pap?

YesNo
Have you ever had an infection of your uterus, tubes, or ovaries (PID)?

YesNo
Prior Gynecological surgeries
Have you ever had Chlamydia, gonorrhea, herpes, genital warts or any other sexually transmitted disease?

YesNo
Do you have frequent vaginal infections/abnormal discharge?

YesNo
Are you sexually active?

YesNo
Do you have more than one sexual partner?

YesNo
Do you have pain or bleeding with intercourse?

YesNo
When was your last Mammogram?
Was it normal?

YesNo
Any other significant past gynecological history?
V. Contraception
Current Method:

NoneCondomsTubal LigationPillsIUDNuvaRingESSURERhythmVasectomyDiaphragmWithdrawalFoamOther
VI. Family History

RELATIONSHIP

Any family history of:

DiabetesHeart DiseaseHigh CholesterolAlzheimer'sStrokesBreast CancerUterine CancerOvarian CancerOther CancersOsteoporosis
VII. General Medical History
Do you have any ongoing medical problems?
Prior surgeries?
List current medications:
List vitamins and herbal supplements including doses:
Allergies to medications and reaction:
Allergies to food and reaction:
Allergies to the environment and reaction:
List childhood illnesses:
Has your weight changed in the last year?

YesNo
If yes, how much

Do you have problems with the following?

	YES	NO
Head, eyes, ears, nose & throat (convulsions, visual difficulty, seizures, etc)
Breathing (cough, asthma, TB, valley fever)
Hypertension
Diabetes
Heart Disease (heart attack, palpitations, chest pain, murmur).
Breast Discharge (milky, watery, bloody), Pain, or Breast Lumps
Nausea, Vomiting, Diarrhea, Blood in Stool, Hepatitis
Kidney or Bladder Infection, Stones, Blood in Urine
Skin Problems (including excessive hair, hair loss, acne)
Emotional Problem (depression, suicide attempts, anxiety)

MEDICAL HISTORY FORM