Patient History
DEMOGRAPHIC INFORMATION
Name
FIRST NAME
MIDDLE INITIAL
LAST NAME
DATE OF BIRTH
/
Month
/
Day
Year
Date
SEX
SOCIAL SECURITY
RACE
ETHNICITY
LANGUAGE
YOUR ADDRESS
ADDRESS
Street Address Line 2
CITY
STATE
ZIP
MARITAL STATUS:
SINGLE
MARRIED
PARTNER
DIVORCED
WIDOWED
ARE YOU:
PREGNANT (Check if applicable)
NURSING (Check if applicable)
Whom may we thank for referring you to our practice
CONTACT INFORMATION
HOME PHONE
Format: (000) 000-0000.
WORK PHONE
Format: (000) 000-0000.
EXT
CELL PHONE
Format: (000) 000-0000.
EMAIL
example@example.com
EMERGENCY CONTACT INFORMATION
FIRST AND LAST NAME
RELATIONSHIP TO PATIENT
HOME PHONE
Format: (000) 000-0000.
CELL PHONE
Format: (000) 000-0000.
ADDRESS
ADDRESS
Street Address Line 2
CITY
STATE
ZIP
PRIMARY CARE PHYSICIAN NAME
PRACTICE NAME
ADDRESS
ADDRESS
Street Address Line 2
CITY
STATE
ZIP
PHONE NUMBER
Format: (000) 000-0000.
PHARMACY NAME
PHONE NUMBER
Format: (000) 000-0000.
Address
ADDRESS
Street Address Line 2
CITY
STATE
ZIP
PRIMARY INSURANCE
MEMBER ID
RELATIONSHIP TO POLICY HOLDER
GROUP #
POLICY HOLDER'S NAME
POLICY HOLDER'S DOB
2 SECONDARY INSURANCE
MEMBER ID
RELATIONSHIP TO POLICY HOLDER
GROUP #
POLICY HOLDER'S NAME
POLICY HOLDER'S DOB
EMPLOYMENT STATUS:
Employed
Unemployed
Student
Retired
LAST DEGREE EARNED:
HIGH SCHOOL
COLLEGE
GRADUATE SCHOOL
CURRENT OCCUPATION
BUSINESS PHONE
Format: (000) 000-0000.
Back
Next
NAME
DATE OF BIRTH
-
Month
-
Day
Year
Date
What is the reason for your visit today
GYN History
Age of your first period
First day of your last period:
-
Month
-
Day
Year
Date
Cycle Length (In days)
Flow:
Heavy
Moderate
Light
Age of Menopause
Current birth control
Desired birth control
Date of last Pap Smear
-
Month
-
Day
Year
Date
Date of last Mammogram:
-
Month
-
Day
Year
Date
Do you have or have you ever had any of the following? Mark all that apply:
Abnormal Pap Smear
Abnormal Mammogram
Urinary Problems
Pelvic Pain
Abnormal period
Abnormal Bleeding
Painful Intercourse
Missed periods without pregnancy
IUD placed in past
Herpes
Gonorrhea
Chlamydia
Genital Warts
Other
Abnormal Pap Smear: If yes, year(s)
Abnormal Pap Smear: Diagnosis
Abnormal Mammogram: If yes, explain:
OB History
Have you ever been pregnant?
Yes
No
Total # of Pregnancies
Abortions
Miscarriages
Still Born
# of Living Children
Have you gone into spontaneous labor before 37 weeks?
Yes
No
Please fill out the following for each pregnancy
Rows
Date (mo./yr)
Single or Multiple
C/S or Vaginal
Baby Weight
Complications
1
2
3
4
5
Surgical History: (List all surgeries and approximate dates)
Rows
DATE
TYPE OF SURGERY
1
2
3
4
5
6
7
8
9
10
Do you have any medication or drug allergies?
Yes
No
Please list any allergies
Rows
Allergy
Reaction (Rash, swelling,itching, etc.)
1
2
3
4
Please list all Medications:
Rows
Medication
Dosage
Frequency Taken
1
2
3
4
5
6
7
8
9
10
11
12
Social History
Have you used tobacco/smoked/vaped?
Yes
No
How long?
If a current smoker, how much? (pk/day)
If former, quit date
-
Month
-
Day
Year
Date
Do you use illegal/recreational drugs?
Yes
No
Do you drink alcohol?
Yes
No
If yes:
Light
Moderate
Heavy
Do you exercise?
Yes
No
If yes how long
How often
Back
Next
Medical/Family History
# of Parents Living
Total # of Siblings
Please check all health problems you have experienced personally or have a family history of below:
Rows
PERSONAL HISTORY
FAMILY HISTORY
LIST FAMILY MEMBER. INCLUDE MOTHER OR FATHER’S SIDE
BREAST PROBLEMS
BREAST CANCER
OVARIAN CANCER
ANXIETY
ANEMIA
ASTHMA
ARTHRITIS
BACK PAIN
BIRTH DEFECTS
BLOOD CLOTS
BLOOD IN URINE
BLOODY/DARK STOOLS
CHEST PAIN
CONSTIPATION/ULCERS/GI PROBLEMS
CONVULSIONS
DIABETES (type 1 or 2)
DEPRESSION
SKIN DISEASE
FREQUENT URINATION
GALLBLADDER DISEASE
GLAUCOMA
HEADACHES
HEARING LOSS
HEPATITIS
HEART ATTACK
HEART DISEASE
HIGH BLOOD PRESSURE
INFERTILITY
KIDNEY DISEASE/STONES
OSTEOPOROSIS
PNEUMONIA
SEXUAL CONCERNS
SHORTNESS OF BREATH
STROKE
THYROID DISEASE
CANCER
OTHER
If you checked any personal history, please explain:
Preview PDF
Submit
Should be Empty: