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Westlake Gynecology & Women’s Healthcare PATIENT MEDICAL DATA Name____________________________________________________ Age______ DOB__________ S M D W Date______________ Preferred Name_________________________________________ Home Phone_____________________ Cell Phone______________________ Occupation___________________________ Reason for visit: Referral ______ Routine _____or other: _______________________________ Circle all that apply to you: Pre-menopause Peri-menopause Menopausal Hysterectomy Number of: Pregnancies ______ Deliveries ______ Miscarriages ______ Abortions ______ Ectopic ______ Date of last Menses:___________ Cycle length:_________ Duration __________ Pain: Y____N____ Heavy: Y____N____ #of Children _____Ages:__________________ # of Vaginal Births _____ #of C-Sections ______ #of Premature Births_____ My last pap smear date: _____________ normal: Y___ N___ My last mammogram date: _______________normal: Y___ N___ MEDICAL HISTORY (circle all that apply past or present): Acne Colitis Endometriosis Heavy Bleeding Irritable Bowel Pelvic Pain Anxiety Depression Epilepsy Hepatitis Kidney Stones Stroke Arthritis Diabetes Fibrocystic Breasts HPV Migraines Thyroid Problems Asthma Dysplasia Genital Warts Hypertension Obesity Urinary Leakage Blood Clots Emphysema Heart Disease Infertility Osteoporosis Other Conditions or cancer history (list specific organ/satage/treatment):________________________________________________________________________ _______________________________________________________________________________________________________________________________________ SURGERY (list organs/ types of procedures/ year performed/minor gyn procedures/ovarian/uterine):________________________________________________ _______________________________________________________________________________________________________________________________________ ALLERGIES (circle below or list / specify reaction; rash, swelling, loss of breath):________________________________________________________________ Penicillin Sulfa erythromycin Codeine Iodine tapes List any other allergies_________________________________ ______________________________________________________________________________________________________________________________________ MEDICATIONS (list names and doses of prescriptions, vitamins, herbal products, supplements):___________________________________________________ ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ Tobacco use: _________ ppd:_______ Past/ Present Anesthesia problems: _________ Alcohol use:__________ Drug use:___________ IV Drugs_____________ Concerns about HIV or Hepatitis? _________ FAMILY HISTORY (circle or list those only in your immediate family- parents/siblings): Arthritis Endometriosis Heart Attack Stroke Cancer: Breast Colon Ovary Uterus Depression Fibroids Melanoma Thyroid Other Cancers: ________________________________________ ________ Diabetes Genetic Disease Osteoporosis _______________________________________________________________ Are you or have you been sexually active? Y Current Contraception (circle all that apply): Condoms OC Pills Diaphragm Depo-Provera Tubal Abstinence IUD Vasectomy None Are you interested in a new form of contraception? Y___ N N___ Maybe___ Withdrawal Do you want to get pregnant? Y___ N/A N___ My most important health issue is routine screening or________________________________________________________________________________________
