PATIENT
MEDICAL HISTORY

First name

Last name

Date

Age

Reason for today’s visit

First day of last menstrual period

Social History

Sex at birth
Male Female

Sex of sex partners (select all that apply)
Male Female Transgender Unknown

Occupation

Gynecological History

Age at time of
first menses

Frequency of
menstrual periods

Number of days of bleeding
Total Heavy Light

Bleeding between periods
Yes No

Pain with periods
Yes No

Pain with intercourse
Yes No

Other pelvic pain
Yes No

Are you sexually active?
Yes No

Previous IUD use
Yes No

Abnormal pap smears
Yes No

Any history of
Gonorrhea
Herpes
Syphilis
Chlamydia

Venereal warts
HIV
Hepatitis
Pelvic inflammatory disease

Fibroid uterine tumors
Endometriosis
Infertility

Treatment description

Do you have (select F = frequently R = rarely N = never)

Number of
Pregnancies

Miscarriages

Abortions

Ectopic Pregnancies

Year

Wks

Delivery Type

Weight

Anesthesia

Complications

Add another?

Were your pregnancies complicated by

Hemorrhage
Yes No

Infection
Yes No

Infection with group B strep
Yes No

Diabetes
Yes No

Other complications of pregnancy

Personal History

Any history of cancer
Yes No

Other Illnesses

Patient Medications

Medication

Dosage

Indication

Add another?

Allergies

Medication

Reaction

Add another?

Surgeries

Surgery

Date

Problems

Add another?

Any hospitalizations?

Do you use

Tobacco

Alcohol

Other drugs

Vaccines

Flu shot this year
Yes No

Rubella (MMR) vaccine
Yes No

Have you had chickenpox or the vaccine?
Yes No

Hepatitis
Yes No

Hepatitis vaccine
Yes No

Gardasil® or HPV
Yes No

Date of last tetanus (TDAP) shot

If you are between 18 and 45 years old

Do you have any cats?
Yes No

Do you eat raw meat?
Yes No

Do you or your partner ever use
hot tubs, steam rooms or jacuzzis?
Yes No

Are you or partner of
Mediterranean descent?
Yes No

Are you or partner Jewish?
Yes No

Are you or partner African-American?
Yes No

Who in your family had: (M=Mother, F=Father, S=Sibling, G=Grandparent)

High Blood Pressure
Bleeding Disorders
Muscular Dystrophy
Mental Illness
Endometriosis
Sickle Cell Anemia

Tay-Sach's Disease
Spina Bifida
Cancer
Osteoporosis
Heart Disease
Thallasemia

Alcoholism
Depression
Gout
Birth Defects
Cystic Fibrosis

Lupus
Glaucoma
Diabetes
Suicide
Alzheimer’s

Review of Systems

Last cholesterol test date

Results

Do you take vitamins?
Yes No

Last mammogram test date

Do you perform breast self-exams?
Yes No

Do you exercise regularly?
Yes No

Have you ever had a colonoscopy?
Yes No

Will you accept a blood transfusion to save your life?
Yes No

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