Please list all medications you are allergic to:

Medication: med allergy Reaction: med reaction

Medication: med allergy Reaction:  med reaction

Medication: med allergy Reaction: med reaction            

Please list any current medications and doses, including over-the-counter medications, birth control methods, herbs, supplements, and vitamins.


Medication: medication Dosage: dosage
Medication: medication  Dosage: dosage    
Medication: medication  Dosage:  dosage    
Medication:   medication Dosage:  dosage
Medication:   medication Dosage:  dosage    
Medication:   medication Dosage:  dosage    

How many people have you had sex with in the last 3 months? enter number
In the last 12 months? enter number

Menstrual History:
Age when periods started: age
When did your last period start?    date    
Periods come every days days and last    how many days  days.
Periods are usually:    Please Select lightmoderateheavyirregular    

 Pregnancy History:
Are you pregnant now?     yes     no     unsure       
Have you ever been pregnant?    yes     no    
If yes, how many times?    #    
Number of live births:    #    Number of abortions:    #    
Number of miscarriages: # Number of ectopic: #
Any problems with pregnancy or birth?    yes     no    
If yes, please describe:
pregnancy/birth issues