MEDICAL HISTORY INFORMATION

Southwest WomanCare OBGYN

7789 Southwest Fwy, Suite 400, Houston, TX 77074 | (832) 649-4273
MEDICAL HISTORY INFORMATION
Full Name*
Date of Birth*

MonthDayYear
Date
Address*

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
example@example.com
Reason for Visit*
Who Referred You?*
Please Describe your:
Medical History:*
Surgical History:*
Family History:*
Social History:
Smoking*

YesNo
Alcohol*

YesNo
Illicit Drugs*

YesNo
Sexually Active*

YesNo
With

MaleFemaleBoth
Gynecology History:
Age of First Cycle*
Frequency*
First day of last menstrual cycle*

MonthDayYear
Date
Last Pap Smear*

MonthDayYear
Date
HPV Vaccine*

YesNo
Flu Vaccine*

YesNo
Contraception*
Mammogram*
Colonoscopy*
Obstetrical History:
Total Pregnancies*
Full term*
Preterm*
Miscarriages*
Ectopic*
Terminations*
First Child
Year
Gender
Weight
Vaginal/CS
Complications
Second Child
Year
Gender
Weight
Vaginal/CS
Complications
Third Child
Year
Gender
Weight
Vaginal/CS
Complications
Fourth Child
Year
Gender
Weight
Vaginal/CS
Complications
Fifth Child
Year
Gender
Weight
Vaginal/CS
Complications
Medications*
Allergies*
Print Name*
Signature*

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