PATIENT
MEDICAL HISTORY
First name
Last name
Date
Age
Reason for today’s visit
First day of last menstrual period
Social History
Marital status
Single
Married
Divorced
Widowed
Remarried
Sex at birth
Male
Female
Current gender
Male
Female
FTM
MTF
Other
Sex of sex partners
(select all that apply)
Male
Female
Transgender
Unknown
Have you completed
Grade School
High School
Junior College
College
Graduate School
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
Method of birth control
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)
Night sweats
F
R
N
Hot flashes
F
R
N
Vaginal dryness
F
R
N
Difficulty sleeping
F
R
N
Memory loss
F
R
N
Depression
F
R
N
Loss of sex interest
F
R
N
Anxiety
F
R
N
Urine loss cough/sneeze
F
R
N
Number of
Pregnancies
Miscarriages
Abortions
Ectopic Pregnancies
Year
Wks
Delivery Type
Weight
Anesthesia
Complications
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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
Urinary tract infections
Stomach ulcers
High blood pressure
Thyroid disease
Lupus
High cholesterol
Eating disorders
Physical/sexual abuse
Liver disease
Stroke
Heart disease
Broken bones
Mental illness
Osteoporosis
Asthma
Depression
Migraines
Diabetes
Seizures
Hepatitis
Blood clots
Any history of cancer
Yes
No
Cancer type
Cancer treatment type
Other Illnesses
Patient Medications
Medication
Dosage
Indication
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Allergies
Medication
Reaction
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Surgeries
Surgery
Date
Problems
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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
Muscle or joint pain
Blood in urine
Muscle weakness
Trouble walking
Leg swelling
Breast lump
Nipple discharge
Numbness
Painful urination
Nighttime urination
Frequent urination
Involuntary urine loss
Constipation
Painful bowel movements
Blood in stool
Weight change
Difficulty breathing
Chest pain
Palpitations
Rash
Non-healing sores
Hair loss
Excessive bleeding or bruising
Hearing loss
Sinus problems
Vision problems
Mouth sores
Unusual moles that won’t heal
Fainting
Fatigue
Headaches
Nausea
Vomiting
Indigestion
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