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  • New Patient Health History Form

  • Date of Birth
     / /
  • Date of last period
     / /
  • What is your reason for visit today?

  • PAST MEDICAL HISTORY

  • Please mark any conditions that you have now, or have had in the past:
  • Rows
  • Rows

  • SURGICAL HISTORY

    Please list all surgeries you have had, and the date and location of surgery

  • GYNECOLOGIC HISTORY

  • Have you gone through menopause?
  • What is your average flow?
  • Do you have clots?
  • Do you have bleeding between periods?
  • Do you have cramps?
  • Do you have pelvic pain outside of your periods?
  • Do you use birth control?

  • OB HISTORY

  • Fill in the information below about each of your pregnancies

  • Pregnancy #1

  • Date of delivery
     - -
  • Gender

  • Pregnancy #2

  • Date of delivery
     - -
  • Gender

  • Pregnancy #3

  • Date of delivery
     - -
  • Gender

  • Pregnancy #4

  • Date of delivery
     - -
  • Gender

  • Pregnancy #5

  • Date of delivery
     - -
  • Gender

  • Pregnancy #6

  • Date of delivery
     - -
  • Gender

  • Pregnancy #7

  • Date of delivery
     - -
  • Gender

  • Pregnancy #8

  • Date of delivery
     - -
  • Gender

  • SOCIAL HISTORY

  • Do you wear a seatbelt?
  • Do you do self breast exams?
  • Do you drink milk?
  • Do you eat cheese or other dairy products?
  • Do you take calcium?
  • How much do you exercise?
  • Are you sexually active?
  • Do you have sex with?
  • New sexual partner?
  • Lifetime sexual partners
  • Marital status
  • Current or former smoker?
  • Do you chew tobacco or betel nut?
  • Which of the following best describes your alcohol use?
  • Have you binged alcohol in the last year (4 or more drinks in a 2 hour period)?
  • Have you had episodic drinking in the last year (4 or more drinks in a single day)?
  • History of marijuana use?
  • Any history of abusing prescription or illegal drugs?
  • Any history of abuse?

  • ROUTINE HEALTH SCREENINGS

  • Results of last Pap smear
  • Any history of abnormal paps?
  • Results of last mammogram:
  • Ever had any abnormal mammogram?
  • Results of last DEXA

  • FAMILY HISTORY

  • Please mark any condition that a blood relative of your has.
  • Date
     / /
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  • Should be Empty: