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 PATIENT MEDICAL HISTORY QUESTIONNAIRE Name:_______________________________________________ DOB:_____________________________________ Age __________________ Marital Status ___Single ___ Married ___Divorced ___Widowed Preferred Pharmacy __________________________________________ ___ Reason for visit ________________________________ Primary Care Doctor/Referring Physician _________________________________________________ List all medications/vitamins that you are taking (please include dose): _____________________________________ Dosage __________ ______________________________________ Dosage __________ _____________________________________ Dosage __________ ______________________________________ Dosage __________ Which prescriptions do you need refilled today? _______________________________________________________________________ List all medications you are ALLERGIC to: ________________________________________________________________________________ MENSTRUAL HISTORY (even if postmenopausal or no longer having periods) What is your LMP (Last menstrual period)?___________________ Menopausal ___Y ___ N Age at first period: ____________ years. If your menstrual periods are regular; periods start every: ___________ days If your menstrual periods are irregular; periods start every: _____ to _____ days Duration of bleeding: ___________ days Does bleeding or spotting occur between periods? ____ Yes ____ No Does bleeding or spotting occur after intercourse? ____ Yes ____ No Is pain associated with periods? ____ Yes ____ No BIRTH CONTROL HISTORY Abstinence _________ What birth control method(s) do you currently use? _____________________________________________________________ PREGNANCY HISTORY Have never been pregnant ___________ Number of Pregnancies _____________ Number of Deliveries _________________ Vaginal ________ C/S ________ Number of Living Children __________ Number of Miscarriages _____________ Number of Abortions _________________ Any complications of pregnancy or delivery __________________________________________________________________________ PAST OBSTETRICAL/GYNECOLOGICAL SURGERIES None ___________________ Procedure ___________________________________ ___________________________________ Date Surgeon ________________ ____________________________________________ ________________ ____________________________________________ PAST SURGICAL HISTORY (Not OB/GYN) None __________________ Procedure __________________________________ __________________________________ __________________________________ Date Surgeon ________________ ____________________________________________ ________________ ____________________________________________ ________________ ____________________________________________ PAP SMEAR/MAMMOGRAM HISTORY Date of last pap smear: ____________________________ What were the results of this pap smear? ___________________ Have you had abnormal pap smears? ____Yes ____No Have you had treatment for abnormal pap smears? ____ Yes ____ No What type of treatment(s) have you had? __________________________________ Date ____________________ Date of last mammogram (if over 40): ______________________________________ Have you had an abnormal mammogram? ___ Yes ___ No OTHER PAST GYNECOLOGICAL HISTORY Check any that apply None _________________
_____ Vaginal infections _____ Yeast infections _____ Condyloma/Warts _____ Chlamydia _____ Pelvic Pain _____ Ovarian Cysts _____ Endometriosis _____ Infertility _____ Ovarian Cancer _____ Uterine Cancer _____ Pelvic inflammatory disease _____ Genital Herpes _____ Gonorrhea _____ Polycystic Ovaries _____ Fibroids _____ Breast Cancer Social Hystory Do you currently? Work _____ No _____ Yes If yes, what is your occupation? ______________________________________________ Smoke _____ Yes _____ packs/day ______ No Have you ever? _____ No _____ Yes Drink Alcohol _____ No _____ Yes _____ wine (glasses/day); _____ beer (glasses/day) _____ hard liquor (oz/day) Use illicit drugs _____ No _____ Yes ___________________ type ___________________ amount PAST MEDICAL HISTORY (check if currently treated or have been treated) None __________ _____ Anxiety _____ Asthma _____ Arthritis _____ Depression _____ Blood Clots _____ Thyroid problem _____ Reflux/GERD _____ Seizures _____ Breast Cancer _____ Migraines _____ Eating Disorder _____ Stroke _____ Osteopenia _____ Gallstones _____ Diverticulosis _____ High Cholesterol _____ Kidney problem _____ Hepatitis _____Other_(please list any medical problems) _____ Diabetes _____ Heart Disease _____ Colon Ca _____Osteoporosis _____ Irritable Bowel FAMILY HISTORY _____ Diabetes ____ Heart Disease _____ Breast Cancer _____ Endometrial Ca. ____ Colon Cancer _____ High cholesterol If yes to any, please list affected relatives __________________________________________ _____ Ovarian Cancer _____ Other OTHER SYMPTOMS Have you had recent had? _____ weight loss _____ hair loss _____ breast discharge/lump/pain _____ change in urinary function _____ hair growth _____ change in energy _____ difficult sleeping _____ other _____ weight gain _____ hot flashes _____ vaginal dryness IF YOU ARE PREGNANT OR PLANNING TO BE PREGNANT IN THE NEAR FUTURE Have you or the baby’s father or anyone in your families ever had any of the following: _____ Down Syndrome? If yes, who? _______________________________________ _____ Other Chromosomal abnormality? If yes, who? _______________________________________ _____ Neural tube defect (spina bifida)? If yes, who? _______________________________________ _____ Hemophilia or other coagulation problem? If yes, who? _______________________________________ _____ Cystic Fibrosis? If yes, who________________________________________ _____ Muscular Dystrophy? If yes, who? _______________________________________ _____ Heart malformation? If yes, who? _______________________________________ _____ Sickle cell disease? If yes, who? _______________________________________ _____ Thalessemia? If yes, who? _______________________________________ ___________________________________________________________ __________________________________ Signature of Patient Date