Survey
* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project
Download PATIENT HEALTH HISTORY
Document related concepts
no text concepts found
Transcript
PATIENT HEALTH HISTORY Name: ________________________________ DOB:______________ Age: ______ Date: _______________ Referred by: _______________________________ Primary Care Doctor: ____________________________ Gynecology History Date of last menstrual period ______________________ Age at first period _______________________________ Current birth control _____________________________ Previous abnormal Paps: Yes No Previous sexually transmitted disease or PID: Yes No Duration of periods __________________________ Flow: Light Moderate Heavy Date of last Pap smear _______________________ Date of last mammogram _____________________ Type ______________________________________ List previous surgeries or hospitalizations: _____________________________________________________________ ________________________________________________________________________________________________ Current medications: ______________________________________________________________________________ ________________________________________________________________________________________________ Allergies: ________________________________________________________________________________________ Smoking: _____________ Alcohol: ______________ Recreational drug use: ______________________________ Obstetric History Number of pregnancies__________________________ Cesarean Sections _________________________ Miscarriages _______________________________ Tubal pregnancies _________________________ Living children ______________________________ Premature births _______________________ Abortions ______________________________ Weight of children at birth _________________ Describe any problems with any pregnancy: ___________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ General History Have you or any member of your family ever had any of the following? If yes, indicate whom. Serious heart trouble_________________________ Cholesterol problems ________________________ High blood pressure _________________________ Stroke ____________________________________ Anemia ___________________________________ Diabetes __________________________________ Thyroid disease _____________________________ Osteoporosis _______________________________ Migraine headaches _________________________ Blood clots _________________________________ Lung disease ________________________________ Hepatitis/Liver disease ________________________ Kidney disease/Infection ______________________ Drug/Alcohol abuse __________________________ Depression _________________________________ Epilepsy/Seizures ____________________________ Bowel/Rectal disease _________________________ Cancer history: In addition to yourself, please include information for parents, siblings, grandparents, aunts, uncles, children, or grandchildren. YOU SIBLINGS CHILDREN MOTHER’S SIDE FATHER’S SIDE Breast Cancer _____ _____ _____ _____ _____ Ovarian Cancer _____ _____ _____ _____ _____ Endometrial Cancer _____ _____ _____ _____ _____ Colon Cancer _____ _____ _____ _____ _____ Other _____ _____ _____ _____ _____
