Patient History Form

Patient History Form

Today’s Date___/___/___

Patient Mailing Address:_____________________________________________________________________________ Hand Preference: Right Left Both Race/Ethnicity(Optional):

Referring Physician and Address: _________________________________________________________ Primary Care Provider / Practice: _________________________________________________________ Reason for Visit: ______________________________________________________________________

Please List ALL Current Medications and Supplements (include over the counter, non-prescription, prescription medications, hormonal birth control, vitamins, home remedies, and herbs):

Medication Name Dose of Medicine # times taken per day

1. 2. 3. 4. 5. 6. 7. 8. 9.

Do you have any allergies Yes No

If yes, please check all that apply:

Anesthesia Codeine Penicillin Iodine Food

Latex Morphine Sulfa Aspirin Bee Stings

Other Allergies: Reaction:

1. 2. 3.

Have you ever had surgery? Yes No Please check/date year performed to all that apply. List any additional:

Appendectomy Thyroid surgery Women’s Section Only:

Colonoscopy _____(year) Tonsillectomy Beast- lumpectomy

Cosmetic surgery Bladder surgery

Dental Breast- needle biopsy

Gallbladder Breast- reduction

Heart bypass surgery Breast-enlargement

Heart stent Breast-excisional biopsy

Heart surgery(other) Breast-mastectomy

Heart valve replacement D&C

Hemorrhoid surgery Endometrial ablation

Hernia repair Hysterectomy, partial/total

Lithotripsy(kidney stone) Laparoscopy

Obesity Surgery (gastric bypass) Ovaries-removal of one/both

Orthopedic surgery(Back, knee, hip, etc) Tubal ligation

2 Have you or others in your immediate family (parents, grandparents, brothers, sisters, children, or grandchildren) had any of the following? (Please check all that apply):

Condition Self Family Member (List Relation) Specify Type (if applicable) Abdominal Aneurysm Alzheimer’s Disease Anemia Angina Anxiety Arthritis Bladder Disorder Blood Clots Blood Transfusion Breathing Difficulty Cancer Chronic Pain Colon Polyps Depression Diabetes Fibromyalgia Gerd Headaches/chronic Hearing Problems

Heart Disease/Heart Attack High Blood Pressure High Cholesterol

Infectious Disease (Hepatitis /HIV) Kidney Disease/stones Liver Disease Lung Disease/Asthma Lupus Memory Loss Menstrual problems Multiple Sclerosis Muscle Disease Osteoporosis Parkinson’s Disease Psychiatric Condition Seizures Sleep Disorders Stomach Problems/ulcer Stroke Sudden Death Thyroid disorder Vascular Disease Vision problems/Glaucoma

3 Family History:

Relative Age, if living Health (Good or Bad) Age at Death

Father Mother Sisters

Brothers

Yes No

Do you smoke cigarettes? If yes, how many packs per day?

Do you drink alcohol? If yes, how many drinks per day?

Have you used recreational drugs? If yes, what type and when?

What is your level of physical activity? Limited Moderate Highly Active-explain________

Do you follow a particular diet? Yes No _________________________

What is your current occupation: No

Gynecological

Pregnancies (include all pregnancies, miscarriages, abortions, ectopic pregnancy, stillbirths) Include problems such as: premature, preterm labor, preeclampsia, gestational diabetes, etc.:

Preg. Year # weeks pregnant at delivery

Female

/male Birth weight Cesarean/vaginal Place of delivery Doctor Problems 1. 2. 3. 4. 5. 6.

How old were you when you had your first menstrual period? ___________ First day of last menstrual period: ______________________

Are your periods regular? Yes No/Explain:___________________________________ How long does your normal period last (first bleeding until last bleeding?____________ (Number of days) How far apart are your periods (first day of period to the first day of next)? __________

My menstrual flow is: Light Moderate Heavy Heavy with clots

Cramping with my periods is: None Mild Moderate Severe

Are you having bleeding between menstrual periods? Yes No

Do you bleed after sex? Yes No

If you have been through menopause, how old were you at that time?_________ surgical Natural If you have gone through menopause, have you taken hormone therapy? Yes No

4 Current Birth Control Method

Pills Condoms

Nuvaring Diaphragm/Cervical Cap

Patch Suppository, film, foam

Implanon Withdrawal(pull out)

Depo-Provera(shot) Abstinence

Mirena IUD No method

Paragard IUD Trying to get pregnant

Tubal/Vasectomy Hysterectomy

Have you had the vaccine series (Gardasil/Cervarix) for prevention of cervical cancer and genital warts?) yes No Are you sexually active? Yes No Not now but in past Plan to become active

Do you have pain with intercourse? Yes No

Do you have any sexual problems/concerns? Yes No

When was your last pap smear? (for women over 21)___________(Year) Normal Abnormal

When was your last mammogram ?(for women over 40) __________ Normal Abnormal

Have you had a bone mineral density test (DEXA)? Yes No

Did your mother take medication (DES) to prevent a miscarriage while pregnant with you? Yes No

Have you been abused? physically Sexually Emotionally

Have you had any of the following gynecological conditions- use space for all others:

Infertility (trouble getting pregnant) Genital warts(HPV) Ovarian Cysts

Endometriosis Chlamydia Uterine fibroids

Colposcopy (for evaluation of abnormal

pap smear) Gonorrhea Polycystic ovarian syndrome(PCOS)

Dysplasia(precancerous cells on cervix) Herpes Interstitial cystitis

Cryosurgery for treatment of dysplasia Syphilis Urine leakage

LEEP for treatment of dysplasia Pelvic inflammatory disease Do you lose urine when you cough or sneeze?

Laser treatment for treatment of dysplasia Recurrent vaginal infections Recurrent bladder (UTI) infections (3x or

5 Review of Systems: Please check any of the SYMPTOMS below that you experience regularly and ARE NOT already being cared for by another physician:

General Health Skin Vision Ear, Nose, Throat,Neck

Yes No Yes No Yes No Yes No

Overall Good

Health Rashes Vision Change Hearing problem

Appetite Change Bruising Dry Eyes Choking

Fever Itching Blurred Vision Dry mouth

Chills

Mole Sore Eyes Swallowing problem

Excessive Fatigue Acne Watery Eyes Ringing in ears

Weight Loss/Gain Itchy Eyes

Daytime Sleepiness Breast

Heart Pulmonary Gastrointestinal

Yes No Yes No Yes No Yes No

Chest Pains Problem

Breathing Constipation Lump

Irregular Heartbeat Chronic Cough Incontinence Pain

Rheumatic Fever Wheezing Nausea/Vomiting Nipple Discharge

Heart Murmur Diarrhea

Heat Attack

Cong. Heart Failure

Pacemaker

Genitourinary Musculoskeletal Neurological Psychiatric

Yes No Yes No Yes No Yes No

Urinary Urgency Joint Pain Numbness Sad or

Depressed Urinary

Incontinence Back Pain Weakness Disturbance Sleep

Pain Upon

Urination Muscle Aches Shaking Anxiety

Frequency Arthritis Difficulty

Walking/Sitting Psychosis

Speech Difficulty Suicidal

Thoughts

Headaches

Difficulty Thinking

Immune/Allergy Hematology Endocrine

Yes No Yes No Yes No

Itching Anemia Excessive Thirst

Sneezing Frequent Bleeding Heat/Cold

Intolerance

Med. Allergy Frequent Bruising Hair growth/loss

Arthritis Hot flashes

Environmental

Allergy Night sweats

6 To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the physician of any changes in my medical status.

____________________________________ __/__/__ ________________________________ __/__/__