Download The Johns Hopkins University School of Medicine

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:
_
_
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
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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?
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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:_
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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?
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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? __________________________________________
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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
___________________________________________________
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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
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Other:
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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:
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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)
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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
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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
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