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PATIENT HISTORY FORM – FAX TO 4551 DATE: _______________ REFERRING PHY. ________________________ NAME: _____________________________ _____ DOB: ______________ Height:______ Weight:_______ Reason For Visit____________________________________________________________________ Past Medical History: Do you have? Circle all that apply: High Blood Pressure Ulcers, Reflux, Hiatal Hernia Previous DVT or Blood Clots Shortness of Breath, Chest Pain Sickle Cell, Other Blood Disease Thyroid Problems, Goiter MI, Murmur, Irregular heartbeat Asthma, Bronchitis, Emphysema Epilepsy, Seizures Sleep Apnea, CPAP Machine Kidney Disease or Failure Stiff Neck Motion, Pain/Injury Anemia, Bruising, Free Bleeding Recent Cough, Cold, Flu Jaw Clicking, Pain or Stiffness Hepatitis, Jaundice, or Liver Disease Elevated Cholesterol, Triglycerides Back Problems, Arthritis Headaches or Recent Visual Changes Stroke, Paralysis, Other Neurological Disorders Diabetes or Hypoglycemia Glaucoma, or Macular Degeneration Other: _________________________________________________________________________________ OB ASSESSMENT: # of Pregnancies: _____ # Miscarriages: _______ # of Live Births: ________ # Vaginal Deliveries _______ Largest Vaginal Birth: ____lbs. _____oz. # C-Sections: ______ Any Bleeding Complications? NO Yes: ___________________________________ GYN ASSESSMENT: Age First Period: ______ Periods every ____days, Lasts: ______days, Bleeding flow: (Light, Regular, Heavy) LMP: __/___/____ Sexually Active No Yes Pain during period: No Yes (Mild or Severe), Pain during intercourse: No Yes (Mild or Severe) Abnormal Vag Bleeding: No Yes (after intercourse, between periods, most days) Since when? __________ STD Exposures: No Yes (circle) Gonorrhea, Chlamydia, Trichomonas, HIV, Hep B, Hep C, Syphilis Hx of Uterine Fibroids: No Yes, Hx of Ovarian Cyst: No Yes, Hx Abn Pap: No Yes__/__/___ Birth control pills in past? No Yes Age: _____ How many years?__________ Hormones (HRT) in past? No Yes Age: _____ How many years?__________ Health Screening: Last Mammogram: ___/___/____ Last Pap Smear: ___/___/____ Last Colonoscopy: ___/___/____ Last Chest X-ray: ___/___/____ Bone Density: ___/___/____ Normal Normal Normal Normal Normal Abnormal________________________ Abnormal________________________ Abnormal________________________ Abnormal________________________ Abnormal________________________ Past Surgical History: DO YOU HAVE ANY IMPLANTS SUCH AS PACEMAKER, CARDIAC STENTS: _________________ List surgeries you have had: ______________________________________________ _________________________________________ ______________________________________________ _________________________________________ ______________________________________________ _________________________________________ ______________________________________________ _________________________________________ ______________________________________________ _________________________________________ ______________________________________________ _________________________________________ 1 Name: ___________________________________ Family History: Please indicate family member: Father: Living/ Deceased Age: _____ Health Problems: _________________________________________ Mother: Living/ Deceased Age: _____ Health Problems: _________________________________________ Brother: Living/ Deceased Age: _____ Health Problems: _________________________________________ Brother: Living/ Deceased Age: _____ Health Problems: _________________________________________ Brother: Living/ Deceased Age: _____ Health Problems: _________________________________________ Sister: Living/ Deceased Age: _____ Health Problems: _________________________________________ Sister: Living/ Deceased Age: _____ Health Problems: _________________________________________ Sister: Living/ Deceased Age: _____ Health Problems: _________________________________________ Child: Living/ Deceased Age: _____ Health Problems: _________________________________________ Child: Living/ Deceased Age: _____ Health Problems: _________________________________________ Child: Living/ Deceased Age: _____ Health Problems: _________________________________________ Other: ___________________________________________________________________________________ Family History of GYN / GI / Breast Cancer: (Include age at diagnosis) Breast Cancer: ___________________________________________________________________________ Colon Cancer: ___________________________________________________________________________ Endometrial Cancer: ______________________________________________________________________ Cervical Cancer: _________________________________________________________________________ Ovarian Cancer: _________________________________________________________________________ Other Female: ___________________________________________________________________________ Social History: Home environment: Single Married Widowed Lives with spouse Lives alone Lives with family Other: ______________________________________ Divorced ______ yrs. SNF Nursing Home Work History: Employed Unemployed Works at home Retired Disabled LOA (leave of absence) Comments: ______________________________________________________________________________ Have you had any problems with anesthesia? No Yes _______________________________________ Have any blood relatives that had serious problems with anesthesia? No Yes _____________________ Have you been taking steroids any time within the last 12 months? No Yes Indicate which one you are taking: Cortisone, Prednisone, Hydrocortisone, Decadron Are you taking aspirin products or blood thinners? No Yes What are you taking? __________________________________ Smoking/Alcohol History: Do you smoke? No Yes, How much______________ How long _______________ Have you ever smoked? No Yes, How much? _______ How long _______ When did you quit ______ Do you drink alcohol? No Yes, How much?______________________ Do you use illegal or recreational drugs? No Yes 2 Name: _________________________________ Review of Systems: Do you have? Constitutional Weight loss Fever Night Sweats Chills Fatigue Loss of Appetite Genito-Urinary Dysuria Hematuria Urinary Frequency Urinary Incontinence (Stress, Urge, Overflow) Hematologic/Lymph/Immunologic Lumps in Axilla Lumps in Neck Lumps in Groin Easy Bruising Mucosal Bleeding Eyes Blurred Vision Double Vision Musculo-Skeletal Stiffness Neck Pain Joint Pain Back Pain Endocrine Cold or Heat Intolerance Polydipsia (excessive thirst) Polyuria (excessive urination) Ear, Nose, Mouth, Throat Hearing loss Tinnitus Rhinorrhea Altered Smell Altered Taste Odynophagia/ Dysphagia Mouth Sores Sinus Congestion Sore throat Epistaxis Hoarseness Skin Skin Rash Alopecia Nail Changes Cardiac Chest Pains Dyspnea on exertion Orthopena Lower extremity edema Orthostasis/ Syncope Neurological Headaches Seizures Confusion Loss of Balance Numbness Weakness of Limbs Tingling Sensations Progressive Memory Loss Dizziness Gait Changes Psychiatric Anxiety Depression Panic Attacks Mood Alteration Respiratory Cough Sputum Production Hemoptysis Shortness of Breath Platypnea (shortness of breath relieved by lying down) Snoring Gastrointestinal Nausea Vomiting Acid Reflux Constipation Diarrhea Melena (Black or tarry stool) Hematochezia (passing fresh blood during bowel movement) 3
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