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Download Patient History - The Woman`s Group
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Patient: GYNECOLOGIC HISTORY FIRST DAY OF LAST PERIOD: / / ARE YOU SEXUALLY ACTIVE? NUMBER OF SEXUAL PARTNERS (LIFETIME): PRESENT METHOD OF BIRTH CONTROL: ANY RECENT CHANGES IN PERIOD? HAVE YOU EVER HAD SEX? SEXUAL PARTNERS ARE: _______MEN _____WOMEN _____BOTH PATIENT COMMENTS: OBSTETRIC HISTORY NUMBER PREGNANCIES PREMATURE BIRTHS NUMBER ABORTIONS LIVE BIRTHS NUMBER MISCARRIAGES LIVING CHILDREN PERSONAL PROFILE SEXUAL ORIENTATION: HETEROSEXUAL HOMOSEXUAL BISEXUAL MARITAL STATUS: MARRIED LIVING WITH PARTNER SINGLE WIDOWED DIVORCED NUMBER OF LIVING CHILDREN: CURRENT OR MOST RECENT JOB: PERSONAL PAST HISTORY OF ILLNESS MAJOR ILLNESSES ASTHMA PNEUMONIA/LUNG DISEASE KIDNEY INFECTIONS/STONES TUBERCULOSIS SEXUALLY TRANSMITTED DISEASE HIV / AIDS HEART ATTACK/PROBLEMS DIABETES HIGH BLOOD PRESSURE STROKE RHEUMATIC FEVER BLOOD CLOTS IN LUNGS OR LEGS EATING DISORDERS COLLAGEN VASCULAR DISEASE (LUPUS) YES NO UNSURE MAJOR ILLNESSES CHICKEN POX HIATAL HERNIA / ULCERS / REFLUX DEPRESSION / ANXIETY CANCER SEIZURES / CONVULSIONS / EPILEPSY ANEMIA BLOOD TRANSFUSIONS BOWEL PROBLEMS ARTHRITIS / JOINT PAIN / BACK PROBLEM GLAUCOMA CATARACTS THYROID DISEASE YES NO UNSURE BROKEN BONES HEPATITIS / YELLOW JAUNDICE / LIVER DISEASE SOCIAL HISTORY DO YOU SMOKE? IF YES, PACKS PER DAY: YEARS: ALCOHOL: DRINKS PER DAY: DRINKS PER WEEK: RECREATIONAL DRUG USE: IF YES, HOW LONG SINCE LAST USE: (PLEASE PROCEED TO NEXT PAGE) YES NO PATIENT HISTORY The Woman’s Group Linda A. Prentice, M.D. Stephanie Taylor, M.D. Emily Emmet, M.D. PATIENT: BIRTH DATE: REVIEW OF SYSTEMS CONSTITIONAL WEIGHT LOSS WEIGHT GAIN FATIGUE FEVER CHANGE IN HEIGHT EYES DOUBLE VISION SPOTS BEFORE EYES VISION CHANGE GLASSES / CONTACTS EAR, NOSE, THROAT EAR ACHES RINGING IN EARS HEARING PROBLEMS SINUS PROBLEMS SORE THROAT MOUTH SORES DENTAL PROBLEMS CARDIOVASCULAR PAINFUL BREATHING CHEST PAIN DIFFICULTY BREATHING ON EXERTION SWELLING OF LEGS RAPID OR IRREGULAR HEART RATE RESPIRATORY WHEEZING SPITTING UP BLOOD SHORTNESS OF BREATH CHRONIC COUGH GASTROINTESTINAL FREQUENT DIARRHEA BLOODY STOOL NAUSEA / VOMITTING / INDIGESTION CONSTIPATION INVOLUNTARY LOSS OF GAS OR STOOL GENITOURINARY BLOOD IN URINE PAIN WITH URINATION FREQUENT URINATION INCOMPLETE EMPTYING LIST ANY MEDICATION ALLERGIES: YES NO UNSURE GENITOURINARY CON’T INVOLUNTARY / UNINTENDED URINE LOSS URINE LOSS WHEN COUGHING OR LIFTING ABNORMAL BLEEDING PAINFUL PERIODS PREMENSTRUAL SYNDROME (PMS) PAINFUL INTERCOURSE FIBROIDS INFERTILITY DES EXPOSURE ABNORMAL VAGINAL DISCHARGE MUSCULOSKELETAL MUSCLE WEAKNESS MUSCLE OR JOINT PAIN SKIN RASH SORES DRY SKIN MOLES BREAST PAIN IN BREAST NIPPLE DISCHARGE YES NO UNSURE LUMPS NEUROLOGIC SEVERE MEMORY PROBLEMS SEIZURES NUMBNESS DIZZINESS FREQUENT OR SEVERE HEAD ACHES TROUBLE WALKING PSYCHIATRIC DEPRESSION OR FREQUENT CRYING SEVERE ANXIETY ENDOCRINE HAIRLOSS HEAT / COLD INTOLERANCE ABNORMAL THIRST HOT FLASHES HEMATOLOGIC / LYMPHATIC CUTS DO NOT STOP BLEEDING FREQUENT BRUISES ENLARGED LYMPH NODES (GLANDS) REVIEWED BY: DATE REVIEWED:
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