Download Patient History - "Gigi" Doan, MD

PATIENT HISTORY
Full name ________________________________________________D.O.B. ________________ Age_______ Date______________
Reason for today’s visit ________________________________________________________________________________________
Date of last Pap smear ___________ Result __________ Any abnormal Pap smears in the past? Yes/No
If yes, any biopsy or procedure done? ________________________________________________________________________
Last menstrual period __________ Are your periods regular? ________ How long do they last? ______________
Problems with periods? __________________________________________________Age first period began: ___________
Current birth control method_________________________________________________________________________________
Please list date of last: Mammogram ___________/Result __________ Bone density __________/Result _______
List any surgeries and approximate date:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
List all pregnancies (including miscarriages, terminations and ectopics):
Year
Sex
Weight
Fullterm?
Vaginal or
c-section?
Where?
Complications
Have you ever had a STD (sexually transmitted disease)? Yes/No
If Yes, what kind? _______________________________________________________
Were you treated? ______________________________________________________
Have you had the Gardasil vaccine? Yes/No
List current medications you are taking with dosages (including over-the-counter medications and
supplements): ___________________________________________________________________________________________________
Allergies to any medications/latex/iodine and your reaction to it: ________________________________________
Patient name __________________________________________
Patient History, page 2
Do you smoke? ____ How many packs/day? ______ Do you drink alcohol? ____ If yes, drinks/week _______
Occupation: _____________________________________ Spouse/Partner name:_____________________________________
Have you ever been diagnosed with the following? (Circle all that apply)
Asthma
Heart attack/disease
Lung disease
Breast disease
Heart murmur
Migraine headaches
Cancer
Stroke
Neurological disease
Depression/anxiety
Hepatitis
Osteoporosis/osteopenia
Diabetes
High blood pressure
Blood clots
Ovarian cyst or tumor
High cholesterol
Bleeding problems
Infection of tubes or ovaries
Kidney disease
Thyroid disease
Other __________________________________________________________________________________________________________
Is there a member of your family with a history of:
______Bleeding problems
Who? ____________________________________
______Cancer - what type? ___________________
Who? ____________________________________
______Congenital (Inherited) Disease
Who? ____________________________________
______Diabetes/Thyroid Disease
Who? ____________________________________
______Heart Disease
Who? ____________________________________
______High Blood Pressure
Who? ____________________________________
______High Cholesterol
Who? ____________________________________
______Lupus/Rheumatoid
Who? ____________________________________