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Download Maternal Gynerations - Atlanta Obstetrics and Gynecology Associates
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ATLANTA OBSTETRICS & GYNECOLOGY ASSOCIATES A Division of Atlanta Women’s Healthcare Specialists, LLC This form is intended to help us review your entire medical history as well as any present problem you might be experiencing. It will be a permanent part of your medical record and will be kept absolutely confidential. Please take a few moments and fill it out as completely as you can. Check each question that applies to you and put “?” if uncertain. If you have any questions or need help please do not hesitate to ask. NAME:_______________________________________________________ DATE:____/____/____ BIRTHDATE:____/____/____ REFERRED BY:__________________________________________________ REASON FOR VISIT: ROUTINE PHYSICAL PROBLEM AGE:_____________ DESCRIBE PROBLEM: __________________________ _______________________________________________________________________________________________________________ CHECK IF YOU HAVE A CURRENT OR PRIOR MEDICAL PROBLEM: YES MAJOR ILLNESSES Anemia Anxiety/Depression Arthritis / Joint pain Asthma Blood transfusions/disorders Bowel Trouble Breast Cancer Cancer Chronic Lung Disease Diabetes Fracture Glaucoma Heart Murmur Heart Trouble Hepatitis / Jaundice WHEN WAS YOUR LAST TEST OR IMMUNIZATION? DATE Abnormal PAP Smear Bone Density Colonoscopy / Sigmoidoscopy Flu Shot YES High Blood Pressure High Cholesterol Kidney Infections Kidney Stones Pneumonia Rheumatic Fever Sexually Transmitted Diseases Stroke Tuberculosis - TB Thyroid Disease Ulcers OTHER: DATE Tetanus Mammogram Last PAP Smear OTHER: Pneumococcal TYPE PLEASE LIST ANY PAST SERIOUS INJURIES OR HOSPITALIZATIONS: DATE TYPE DATE PLEASE LIST ANY OPERATIONS YOU HAVE HAD: DATE SURGERY / REASON DATE SURGERY / REASON C:\Documents and Settings\kpollard\My Documents\Documents\Website\AWHS Patient History Form.doc NAME:________________________________________________________ DRUG NAME BIRTHDATE:_____/_____/________ PLEASE LIST MEDICATIONS THAT YOU ARE CURRENTLY TAKING: DOSAGE PHYSICIAN DRUG NAME DOSAGE ALLERGIES TO MEDICATIONS / SUBSTANCES (LATEX GLOVES, ETC.?) List: List all “Natural” or Herbal remedies, over the counter drugs, vitamins or minerals you are taking. List: MAJOR ILLNESSES PHYSICIAN FAMILY HISTORY: YES WHAT BLOOD RELATIVE? Asthma Breast Cancer Cancer Depression / Anxiety / Mood Disorders Diabetes Heart Trouble / Murmur High Blood Pressure High Cholesterol Stroke OTHER: YOUR GYN HISTORY Do you use birth control? Yes No Are you Sexually Active? Yes No Current sex partner(s) is/are: Male Female Have you had more than 4 sexual partners in your lifetime? Yes Interested in being screened for sexually transmitted diseases? Yes No No Condoms Nuvaring Depo Provera Birth Control Patch Diaphragm None IUD- Kind Natural Family Plan/Rhythm - Date Inserted: Tubal Ligation Birth Control Pill Vasectomy – Name: Withdrawal Contraceptive Foam/Jelly Other: What age did you have your first period: _____________ How many days are there from start of period to start of next period: ________ days How long does your period last? _______ days Flow: Light Medium Heavy Number of Tampons per day: ____________ Number of Pads per day: ____________ Date of Last Period: ________________ Do you have clots with your periods? Yes No Do you have between periods bleeding? Yes Do you have cramps? Yes No Do you have pain? Yes No Have you gone thru Menopause: Yes No Are you on Hormone Replacement Therapy (hormones)? At what age: ____________ Yes No C:\Documents and Settings\kpollard\My Documents\Documents\Website\AWHS Patient History Form.doc No NAME:____________________________________________________________ Total # of pregnancies Premature Miscarriages/Spontaneous abortion Pregnancy Complications (List): BIRTHDATE:_____/_____/_______ YOUR OB HISTORY NUMBER Full term births Induced abortions Living children Ectopic NUMBER SOCIAL HISTORY PLEASE LIST HABITS Do you use Seat Belt Yes No Do you do a Self Breast Exam Yes No Do you Eat/Drink dairy products Yes No Servings per day: Do you Take Calcium Yes No Name and Dosage: Do you Exercise: None Less than 3 times per week More than 3 times per week Both First Intercourse at Age: ________ Lifetime sexual partners Less than 4 More than 4 Smoking Yes No In past Packs per day: ________ Number of Years: ______ Alcohol Yes No Drinks per day: ________ Drink per week: ________ Drug User Yes No Kind: Frequency: History of abuse Yes No Physical Emotional Sexual ________________________________________________________________ Patient Signature ________________________________________ Date C:\Documents and Settings\kpollard\My Documents\Documents\Website\AWHS Patient History Form.doc
