PATIENT INTAKE HISTORY

PATIENT INTAKE HISTORY
Ko'olau Women's Healthcare, Inc.

642 Ulukahiki St, #209 Kailua, HI 96734

Phone: 808-230-8500 Fax: 808-230-8501
NAME
BIRTH DATE*

MonthDayYear
Date
TODAY'S DATE

MonthDayYear
Date
REFERRED BY:
WHY HAVE YOU COME TO THE OFFICE TODAY?*
IS THIS A NEW PROBLEM?

YESNO
PLEASE DESCRIBE YOUR PROBLEM, INCLUDING WHERE IT IS, HOW SEVERE IT IS, AND HOW LONG IT HAS LASTED.

OBSTETRIC HISTORY
If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse.

(if never pregnant before please type 0 in first row)*

Rows	BIRTH DATE	WEIGHT AT BIRTH	BABY'S SEX	WEEKS PREGNANT	TYPE OF DELIVERY (VAGINAL, CESAREAN
1.
2.
3.
4.
5.

ANY PREGNANCY COMPLICATIONS?
COMPLICATIONS IN PREVIOUS PREGNANCIES

DIABETESHYPERTENSIONBLOOD PRESSUREPREECLAMPSIATOXEMIAOther
ANY HISTORY OF DEPRESSION BEFORE OR AFTER PREGNANCY?

YESNOOther

CURRENT MEDICATIONS

(including hormones, vitamins, herbs, nonprescription medication)

(if currently not on any medication please type NONE in first row)*

Rows	YES	WHICH RELATIVE(S) AND AGE OF ONSET:
NO TO ALL ILLNESSES LISTED BELOW
DIABETES
STROKE
HEART DISEASE
BLOOD CLOTS IN LUNGS OR LEGS
HIGH BLOOD PRESSURE
HIGH CHOLESTEROL
OSTEOPOROSIS (WEAK BONES)
HEPATITIS
HIV/AIDS
TUBERCULOSIS
BIRTH DEFECTS
ALCOHOL OR DRUG PROBLEM
BREAST CANCER
COLON CANCER
OVARIAN CANCER
UTERINE CANCER
MENTAL ILLNESS
DEPRESSION
ALZHIMER'S DISEASE
OTHER

Rows	YES	NO	DESCRIBE
EVER SMOKED? CURRENT SMOKING: PACKS PER DAY: YEARS:
ALCOHOL: DRINKS PER DAY: DRINKS PER WEEK: TYPE OF DRINK:
DRUG USE
SEAT BELT USE
REGULAR EXERCISE: HOW LONG AND HOW OFTEN?
DAIRY PRODUCT INTAKE AND/OR CALCIUM SUPPLEMENTS: DAILY INTAKE:
HEALTH HAZARDS AT HOME OR WORK?
HAVE YOU BEEN SEXUALLY ABUSED, THREATENED, OR HURT BY ANYONE?
DO YOU HAVE AN ADVANCE DIRECTIVE (LIVING WILL)?
ARE YOU AN ORGAN DONOR?

Rows	YES	COMMENTS / DATES
ASTHMA
PNEUMONIA/LUNG DISEASE
KIDNEY INFECTIONS/STONES
TUBERCULOSIS
FIBROIDS
SEXUALLY TRANSMITTED DISEASE/CHLAMYDIA
INFERTILITY
HIV/AIDS
HEART ATTACK/DISEASE
DIABETES
HIGH BLOOD PRESSURE
STROKE
RHEUMATIC FEVER
BLOOD CLOTS IN LUNGS OR LEGS
EATING DISORDERS
AUTOIMMUNE DISEASE (LUPUS)
CHICKENPOX
CANCER
REFLUX/HIATAL HERNIA/ULCERS
DEPRESSION/ANXIETY
ANEMIA
BLOOD TRANSFUSIONS
SEIZURES/CONVULSIONS/EPILEPSY
BOWEL PROBLEMS
GLAUCOMA
CATARACTS
ARTHRITIS/JOINT PAIN/BACK PROBLEMS
BROKEN BONES
HEPATITIS/YELLOW JAUNDICE/LIVER DISEASE
THYROID DISEASE
GALLBLADDER DISEASE
HEADACHES
DES EXPOSURE
INFERTILITY
BLEEDING DISORDERS
OTHER

GYNECOLOGIC HISTORY

Rows	DATE (estimate)	RECEIVED
TETANUS–DIPHTHERIA BOOSTER
HEPATITIS A VACCINE
VARICELLA (CHICKENPOX)VACCINE
MEASLES–MUMPS–RUBELLA (MMR) VACCINE
INFLUENZA VACCINE (FLU SHOT)
HEPATITIS B VACCINE
PNEUMOCOCCAL (PNEUMONIA) VACCINE
TUBERCULOSIS (TB) SKIN TEST: RESULT:

Rows	NOW	PAST	COMMENTS
FREQUENT DIARRHEA
BLOODY STOOL
NAUSEA/VOMITING/INDIGESTION
CONSTIPATION
INVOLUNTARY LOSS OF GAS OR STOOL