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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
NEW PATIENT HEALTH HISTORY FORM (Please only answer applicable questions) Provider you will be seeing: Date of visit: Provider/Person who referred you to our practice: _____ _ Legal Name: Last Name First Middle Name you wish to be called: _________________________________________________________ Age: _____ Date of Birth: Last menstrual period (if applicable): _____________________ Allergies (medication, latex, food, environmental): ______________________________________________________ Partner/Spouse's Name (if applicable): Last Name Age: Date of Birth: CHIEF COMPLAINT: First Middle Date of Marriage (if applicable): ________________ Please describe the reason for your visit today. If applicable, please include all symptoms, duration, and whether they have changed in severity over time: _ _ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ 1 rev 4/2017 MENSTRUAL AND GENITOURINARY HISTORY At what age did you begin to menstruate? What were the start dates of your two most recent menstrual periods? Are your periods regular or irregular? (circle one) If irregular, please describe Number of days between the first day of one period and the first day of the next? Have you ever gone more than 2 months without a period? Yes No When? How long does your menstrual flow last? days Yes No Do you consider your flow to be excessive? If yes, how often are you needing to change your menstrual care products?________________ Yes No Yes No What kind? Do you experience cramps with your period? Do you take medication to alleviate the cramps? Do you bleed between your periods? Yes No Describe: Do you have any noticeable vaginal discharge? Yes No If so, describe (color, consistency, presence of odor, itching, etc.): Do you have a history of frequent UTIs, Bacterial Vaginosis, or yeast infections? If yes, please describe: HEALTH MAINTENANCE HISTORY Never done Date of HPV vaccine: ___________________ Date of last PAP smear: Result: Yes No Have you ever had an abnormal PAP smear? If yes, what treatment did you receive? (freezing, laser, surgery) Date of last mammogram: Result: Yes No Have you ever had an abnormal mammogram? 2 rev 4/2017 SEXUAL HISTORY How many partners have you engaged with sexually in the last month?____________________________ How many partners have you engaged with sexually in the last 6 months?__________________________ Have you been diagnosed and/or treated for any of the following? If yes please include date of treatment and date of last screening. If no please include date of last screening. Chlamydia Yes No Date: _____________ Gonorrhea Yes No Date: ___________ Trichomonas Yes No Date: _____________ Herpes Yes No Date: ___________ Genital warts Yes No Date: _____________ Syphilis Yes No Date: ___________ Hepatitis B Yes No Date: _____________ Hepatitis C Yes No Date: ___________ HIV Yes No Date: _____________ Pelvic inflammatory disease Yes No Do you use anything for STD protection? If so, what?__________________________________________ Do you bleed during or after penetrative intercourse (if applicable)? Yes No N/A Do you have any pain during or after penetrative intercourse (if applicable)? Yes No N/A Do you have difficulty achieving orgasm? Yes No N/A Do you have any concerns about your libido or sex drive? Yes No CONTRACEPTIVE HISTORY Please check any of the following methods of contraception you are currently using or have used. Never used any of these forms of contraception (continue on to next section) Methods Dates of Usage Birth Control Pills Type:_ IUD Type:_ Depo-Provera injection Diaphragm Condoms (male or female) Spermicidal jellies/Foam Sterilization ______male female Other:_ 3 rev 4/2017 OBSTETRICAL HISTORY Yes No Yes No Unsure Yes No Do you currently desire to become pregnant? Do you have plans for pregnancy in the future? Do you currently desire to avoid pregnancy? Total Times Pregnant Term Births _______ Premature Births _________ Miscarriages Elective Abortions _____________________ Ectopic Please list each pregnancy in chronological order in columns below: PREGNANCY Date of pregnancy/delivery 1 2 3 4 5 Miscarriage? Elective Abortion? Ectopic (tubal)? How many months did it take to conceive? Was infertility treatment required? Gestation (weeks) at delivery Mode of delivery (vaginal vs. cesarean) Weight and Sex? Is your current partner the biological parent? (Yes, No, N/A) Is the child healthy? (Y/N) Any complications? 4 rev 4/2017 INFERTILITY HISTORY (If actively trying to conceive) How long have you been attempting pregnancy?______________________ For couples trying to conceive through penetrative sexual intercourse: How many times per week do you have sexual intercourse? ______________________________________ Have you been attempting to time intercourse with ovulation? ___________________________________ Do you douche before or after intercourse? o Yes o No For those using donor sperm, have you attempted insemination at home? _______________________________ If yes, how many times? __________________________________________________________________ Have you monitored to determine the timing of ovulation? o Yes o No Have you been using an ovulation predictor kit? o Yes o No Have you monitored your cervical mucus? o Yes o No Have you monitored basal body temperature? o Yes o No If yes please describe your findings________________________________________________________ Do you use lubricants? o Yes o No If so, what kind? ____________________________________________ Have you received pre-pregnancy counseling? o Yes o No Are you currently taking folic acid supplements? o Yes o No Have you taken gender-affirming hormones? o Yes o No If yes, are you taking them currently? ____________________________________________________ What type(s) of hormones/dosages/ dates taken? __________________________________________ 5 rev 4/2017 PAST SURGICAL HISTORY Please list any and all your prior surgeries in columns below in chronological order: PRODECURE DATE SURGEON DIAGNOSIS PAST MEDICAL HISTORY List all serious medical illnesses or chronic health issues (include hospitalization dates, duration) MEDICATIONS Please list current prescription medications and dosages: Medication/Dose Start Date Medication/Dose 1. 4. 2. 5. 3. 6. Start Date Please list any current nutritional supplements, herbal preparations, or over the counter medications: ____________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Allergies: (medications, latex, food) (Specify allergy and associated reaction): o Yes o No ___________________________________________________ 6 rev 4/2017 SOCIAL HISTORY Yes No Are you on a special diet (vegetarian, lactose-free, low salt, low fat, Kosher, etc.)? Do you exercise regularly? Yes No How often, what type? Yes No Have you had any difficulty or recent change in you habits of sleep, diet or exercise? If so, can you describe? Do you drink alcohol? Yes No Do you currently smoke cigarettes? Approximate drinks per week:_ Yes No # packs per day? ____________ # years? _______ If you are a former smoker, when did you quit? Do you use any illicit or recreational drugs (i.e., marijuana, cocaine)? Describe: Yes No (you may also discuss this with your provider privately) Have you ever been exposed to industrial chemicals, toxic substances or radiation? Yes No If so, state the substance and extent of exposure: What is your blood type? Have you ever had a blood transfusion? Don’t know Yes No Date:____________ Complications?____________ FAMILY HISTORY Check all of the following disorders for which you have a family history. Include which blood relative (mother/father/sister(s)/brother(s), maternal/paternal grandmother or grandfather, maternal/paternal aunt(s) or uncle(s), cousins) had the disorder. Do not include yourself. Cancer (specify) Diabetes Excessive hair growth Heart Disease Neurological (nerve) disorders Hypertension (high blood pressure) Alcoholism or Substance Abuse Thyroid problems (including goiter) Depression Blood Clotting disorders Schizophrenia Early Menopause Other psychiatric problems Osteoporosis Birth defects Recurrent miscarriages Mental retardation Polycystic ovarian syndrome Cystic fibrosis Irregular menstrual cycles Thalassemia or sickle cell disease/trait Infertility Fragile X syndrome 7 rev 4/2017 Other: 8 rev 4/2017 REVIEW OF SYSTEMS Check any of the following that you currently have or have experienced in the past Central Nervous System Genitourinary Seizures Migraine headaches Depression Other:_ Bladder infections (cystitis) Kidney infections Incontinence (leakage of urine) Vaginal Infections Pelvic Pain Other:_ Eyes, Ears, Nose and Throat Wear contact lenses Eye disorders Problem with sense of smell Other:_ Musculoskeletal Unusual muscle weakness Decreased energy/stamina Rheumatoid Arthritis Lupus erythematosus (SLE) Other:_ Cardiovascular Chest Pain Palpitations Rheumatic Fever Heart valve disease High blood pressure Mitral valve prolapse Take antibiotics before dental work or surgery o Other:_________________________ Hematologic Blood clotting disorder Sickle Cell Anemia or trait Other:_ Endocrine Respiratory Shortness of breath Asthma (date of last attack: Bronchitis Pneumonia Blood in sputum Other:_ Diabetes Hypoglycemia Thyroid disorder Increased facial or body hair Baldness Breast discharge (milk, blood, other) Rapid weight gain Rapid weight loss Other:_ ) Gastrointestinal Nausea/vomiting Blood in stool Ulcers Hepatitis Constipation/diarrhea Irritable bowel syndrome Inflammatory bowel disease (Crohn’s, ulcerative colitis) Decreased appetite/anorexia Other: Skin Rash Eczema Vitiligo Problems with skin pigmentation Acne Other: 9 rev 4/2017 Please check all of the following that apply: DATES RESULTS Had or vaccinated for Rubella (German Measles) Had or vaccinated for Varicella (Chicken Pox) Had genetic carrier screening (e.g. cystic fibrosis, sickle cell trait, spinal muscular atrophy, fragile X, tay-sach’s, etc.) Have you had any of the following infertility tests? DATES RESULTS DATES # OF CYCLES Semen Analysis Hormone Labwork/bloodwork (FSH, AMH, Progesterone, etc.) Hysterosalpingogram (HSG) (x-ray of the uterus and tubes using dye) Saline sonogram / sonohysterogram Laparoscopy / Hysteroscopy Other (please specify) Have you had any of the following infertility treatments? TREATMENT Intrauterine insemination (IUI) Clomiphene Citrate (Clomid) or Letrozole (Femara) Gonadotropin injections (e.g. Follistim, Gonal-F, Bravelle, Menopur) Progesterone supplementation In Vitro Fertilization (IVF) Donor Egg Other (please specify) 10 rev 4/2017 PARTNER HISTORY (If actively trying to conceive and produce sperm) Has anyone ever become pregnant by you in the past? Yes No Dates of pregnancies: Age/health of children from other partners: Yes No Have you ever had a semen analysis (sperm test)? If yes, include date and results: Do you come in contact with chemicals or toxins at home or work? Yes No If so, please list: Do you have difficulty achieving or maintaining erections? Yes No Do you have difficulty with ejaculation? Yes No Please list any medical problems: Please list any prior surgeries: What is your blood type (if known): Please list any allergies: ____________ Please list all medications or herbal supplements you are currently taking: Do you drink alcohol? Yes No Do you smoke cigarettes? Yes No Approximate drinks per week: Packs per day? Duration? Do you use any illicit/recreational drugs? Yes No Do you have any family history of infertility, abnormal sperm, or genetic disorders? Yes No Have you ever had any of the following? Chlamydia Yes No Gonorrhea Yes No Syphilis Yes No Genital Herpes Yes No Genital Warts Yes No Urethritis/epididymitis Yes No Prostatitis Yes No Penile discharge or pain Yes No Undescended testicle Yes No Injury to the testicle (s) Yes No Difficulty smelling/tasting Yes No Frequent Headaches Yes No Mumps Yes No DES exposure in the womb Yes No 11 rev 4/2017 Vasectomy Yes No Vasectomy Reversal Yes No Varicocele Yes No Varicocele Surgery Yes No Biopsy of the testicles Yes No Hernia Surgery Yes No Abdominal Surgery Yes No Cancer Yes No High Blood Pressure Yes Yes Yes No No No Diabetes Colitis Seizures Yes No Psychiatric Treatment Yes No Strenuous Exercise Yes No 12 rev 4/2017