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PATIENT HEALTH HISTORY Name: ________________________________ DOB:______________ Age: ______ Date: _______________ Referred by: _______________________________ Primary Care Doctor: ____________________________ Gynecology History Date of last menstrual period ______________________ Age at first period _______________________________ Current birth control _____________________________ Previous abnormal Paps: Yes No Previous sexually transmitted disease or PID: Yes No Duration of periods __________________________ Flow: Light Moderate Heavy Date of last Pap smear _______________________ Date of last mammogram _____________________ Type ______________________________________ List previous surgeries or hospitalizations: _____________________________________________________________ ________________________________________________________________________________________________ Current medications: ______________________________________________________________________________ ________________________________________________________________________________________________ Allergies: ________________________________________________________________________________________ Smoking: _____________ Alcohol: ______________ Recreational drug use: ______________________________ Obstetric History Number of pregnancies__________________________ Cesarean Sections _________________________ Miscarriages _______________________________ Tubal pregnancies _________________________ Living children ______________________________ Premature births _______________________ Abortions ______________________________ Weight of children at birth _________________ Describe any problems with any pregnancy: ___________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ General History Have you or any member of your family ever had any of the following? If yes, indicate whom. Serious heart trouble_________________________ Cholesterol problems ________________________ High blood pressure _________________________ Stroke ____________________________________ Anemia ___________________________________ Diabetes __________________________________ Thyroid disease _____________________________ Osteoporosis _______________________________ Migraine headaches _________________________ Blood clots _________________________________ Lung disease ________________________________ Hepatitis/Liver disease ________________________ Kidney disease/Infection ______________________ Drug/Alcohol abuse __________________________ Depression _________________________________ Epilepsy/Seizures ____________________________ Bowel/Rectal disease _________________________ Cancer history: In addition to yourself, please include information for parents, siblings, grandparents, aunts, uncles, children, or grandchildren. YOU SIBLINGS CHILDREN MOTHER’S SIDE FATHER’S SIDE Breast Cancer _____ _____ _____ _____ _____ Ovarian Cancer _____ _____ _____ _____ _____ Endometrial Cancer _____ _____ _____ _____ _____ Colon Cancer _____ _____ _____ _____ _____ Other _____ _____ _____ _____ _____
