Medical History
Patient Information
Patient Name
Age
Date of Birth
Today’s Date
Marital Status
Single
Married
Divorced
Widowed
Separated
Referred by
Appointment date
Reason for visit
Past Medical History
Abnormal Pap
Anemia
Asthma
Blood Clots
Cancer - Breast
Cancer - Cervix
Cancer - Colon
Cancer - Ovaries
Cancer - Uterus
Coagulation Disorder
Condyloma
COPD
Diabetes
Endometriosis
Heart Disease
High Blood Pressure
High Cholesterol
HIV
HPV
IBD
Kidney Problems
Liver Disease
Obstructive Sleep Apnea
Osteoporosis
Ovarian Cysts
Pelvic Inflammatory Disease
Polycystic Ovarian Syndrome
Pulmonary Embolus
STDs
Thyroid Disease
Uterine Fibroids
Urinary Incontinence
Other
Date of last
Pap Smear
Mammogram
Bone
Density Scan
Colonoscopy
Menstrual History
Date of Last Period
Cycle Length
Flow
Age at Onset
Are you menopausal
Yes
No
Age at onset
Hormone Replacement Therapy
Yes
No
Birth Control Method
Prescription
IUD
Condoms
Foam
Jelly
Diaphragm
Partner Vasectomy
Tubal Ligation
Other
Surgical History
Appendectomy
Bariatric Surgery
Bladder Surgery
Breast Augmentation
Breast Biopsy
Breast Reduction
Cervical Biopsy
Cholectystectomy
Dilation and Curettage
Endometrial Ablation
Hysterectomy
Hysterectomy (tubes/ovaries)
Hysteroscopy
Laparoscopy
LEEP
Lumpectomy of Breast
Myomectomy
Oophorectomy
Ovarian Cyst Removal
Thyroidectomy
Uterine Fibroid Embolization
Tubal Ligation
Other
Pregnancy History
List number of:
Pregnancies
Miscarriages
Ectopics (tubal)
Abortions
Premature
births
Full term
births
Living
Children - list below
Birth date
Sex
M
F
Delivery
Vaginal
C-section
Complications
Birth date
Sex
M
F
Delivery
Vaginal
C-section
Complications
Birth date
Sex
M
F
Delivery
Vaginal
C-section
Complications
Birth date
Sex
M
F
Delivery
Vaginal
C-section
Complications
Birth date
Sex
M
F
Delivery
Vaginal
C-section
Complications
Birth date
Sex
M
F
Delivery
Vaginal
C-section
Complications
Social History
Alcohol Use
Current Drug Use
Past Drug Use
Current Everyday Smoker
Current Some Day Smoker
Former Smoker
Never Smoked
Religious Objection to Blood Transfusion
Family Medical History
Cancer - Breast
Cancer - Cervix
Cancer - Colon
Cancer - Ovaries
Cancer - Uterus
Coagulation Disorder
Diabetes
Endometriosis
Heart Disease (CAD
Hypertension
Thyroid Disease
Uterine Fibroids
Allergies
Any medication allergies?
Yes
No
Drug Name
Adverse Reaction
Drug Name
Adverse Reaction
Medication List
Prescription and/or non-prescription-including vitamins you are currently taking
Medication Name
Dosage
Times Taken
Prescribing Physician
Medication Name
Dosage
Times Taken
Prescribing Physician
Medication Name
Dosage
Times Taken
Prescribing Physician
Medication Name
Dosage
Times Taken
Prescribing Physician
Medication Name
Dosage
Times Taken
Prescribing Physician
Medication Name
Dosage
Times Taken
Prescribing Physician
Medication Name
Dosage
Times Taken
Prescribing Physician
Preferred Pharmacy
Pharmacy Phone