Download LSC Health History 6.26.14

PATIENT HEALTH HISTORY
Name: ___________________________________________________________
Date of Birth:______________________
Last Menstrual Period: ____________________________ Was it normal? Yes
No
If not, what was different? _______________________________________________________________________________
What is your height? ______________ What is your weight? _________________
PREGNANCY HISTORY:
Do you believe you are pregnant?
Yes
No
Have you had a positive pregnancy test?
Yes
No
Were you using birth control when you became pregnant?
Are you currently breast feeding? Yes
No
Where and when? _________________________________
Yes
No
If yes, what method? _____________________
Have you had a physician exam during this pregnancy? Yes
No
How far into the pregnancy were you? ___________
Where and when was the exam? __________________________________________________________________
Have you had an ultrasound during this pregnancy?
Yes
No
How far into the pregnancy were you? ___________
Where and when was the ultrasound?_______________________________________________________________
PREVIOUS PREGNANCIES:
How many times have you been pregnant? (do not include this pregnancy)
Number of Births
Number of Miscarriages
Number of births that were C-Sections _______________ Was a D&C performed?
Any complications with pregnancy?
Yes
No
Any complications following miscarriage?
Any premature deliveries?
Yes
No
Number of Abortions _________________
Any deceased children?
Yes
No
Any at Lovejoy Surgicenter?
Any complications following abortion?
MEDICAL HISTORY:
Have you ever been hospitalized?
Yes
No
When and for what?
What surgeries have you had?
Anesthesia used
- Local
When and for what?
Have you had any complications of anesthesia?
If yes, specify:
Extreme Nausea
Yes
No
No
Yes
Yes
No
No
General
No
Malignant Hypothermia
Is there any family history of problems with anesthesia including:
High fever following surgery
History of malignant hypothermia
Is there any family history of bleeding or clotting disorder?
Yes
Yes
Yes
No
If yes, specify:
Do you have allergies to any medications?
Yes
Do you have any food allergies?
Yes
Do you have environmental allergies? (hay fever, animals) Yes
Do you take any medication on a regular basis?
Yes
Have you used marijuana, cocaine, methamphetamines,
or other street drugs in the last two weeks?
Yes
Do you smoke cigarettes?
Yes
Do you drink alcohol?
Yes
Do you have strong reactions to caffeine? (coffee, cola, chocolate) Yes
Have you ever sought professional counseling,
including abuse and/or drug/alcohol rehabilitation?
Yes
Do you wear contact lenses, have removable
bridgework, or any prosthesis?
Yes
No
No
No
No
If yes, specify:
If yes, specify:
If yes, specify:
If yes, specify:
No
No
No
No
If yes, specify:
If yes, specify:
If yes, specify:
If yes, specify:
No
If yes, specify:
No
If yes, specify:
High fever following surgery
Other:
Extreme nausea
DO YOU HAVE A HISTORY OF:
If yes, specify
Rheumatic Fever
Heart Murmur
Heart Disease
Asthma
Emphysema
Abnormal Chest x-Ray
High Blood Pressure
Migraine Headaches
Diabetes
Stroke
Hepatitis
Liver Disease
HIV/AIDS
Bleeding Abnormalities
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
MRSA
Yes
No
FAMILY HEALTH HISTORY:
If yes, specify
Clotting Disorders Yes
Varicose Veins Yes
Blood clots in veins of legs Yes
Convulsions, seizures or epilepsy Yes
Black out spells or fainting Yes
Thyroid disease Yes
Ulcers Yes
Neurologic Disorders Yes
Temporal-mandibular Joint Disorder Yes
Kidney Disease or Infection Yes
Bladder Infection Yes
Pink, Red or Rose Colored Urine Yes
Psychiatric Disorders Yes
Severe Depression Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Relationship to you
Relationship to you
Heart Disease Yes
No
High Blood Pressure Yes
No
Breast Cancer Yes
No
Diabetes Yes
No
Uterine Cancer Yes
No
Stroke Yes
No
Ovarian Cancer Yes
No
GYNECOLOGIC HISTORY:
Date of last Pap Smear ________________________ Was it normal? Yes
No
Have you ever had an abnormal Pap Smear?
Yes
No
If yes, what was the treatment? __________________________________________________________________
Do you have any history of:
Chlamydia
Yes
No
If yes, specify dates and treatments: ____________________________
Herpes
Yes
No
If yes, specify dates and treatments: ____________________________
Gonorrhea
Yes
No
If yes, specify dates and treatments: ____________________________
Pelvic Inflammatory Disease / PID
Yes
No
If yes, specify dates and treatments: ____________________________
Ovarian Cysts
Yes
No
If yes, specify dates and treatments: ____________________________
Abnormal Periods
Yes
No
If yes, specify dates and treatments: ____________________________
Do you have normal menstrual periods?
Yes
No
At what age did you begin menstruation?
Have you had any other diseases of female organs, or surgery for these conditions?
Yes
No
Have you had any abnormal Mammogram, breast tumors, or other breast problems?
Yes
No
If yes, specify ______________________________________________________________________________________
What birth control methods have you used in the past?
Rhythm
Pills
Diaphragm
Condoms
Foam
Suppositories
Sponge
IUD
Cervical Cap
Depo Provera Injection
Norplant Implant
What method are you requesting for the future? ___________________________________________________________
Patient Signature
Date/Time
___________________________________________
___________________________________________
Counselor Signature
Physician Signature
Date/Time
Date/Time
6/26/14