Medical History Form s1

MEDICAL HISTORY FORM

(All Information is confidential/Please Print)

Name ______Date of Birth______Date ______

Allergies to medications ______

Previous operations and dates ______

Other hospitalizations and dates ______

Please check if you have had any of the following

□Palpitations □Chest Pain □ Murmur

□Hypertension □Stroke/Heart Attack □Shortness of Breath □Bronchitis □Asthma □Irritable Bowel Syndrome □Abdominal Pain □Constipation □GERD □Urinary Tract Infection □ □Kidney Stones □Urgency/Frequency □Leakage of Urine □Joint/Muscle Pain □Osteoporosis □Fractures □Arthritis □Acne □Rash □Scars______□Skin Cancer □Migraines □Dizziness □Headache □Epilepsy/Seizures □Tonsillectomy □Hearing Loss □Near Sighted/Far Sighted □Chronic Sore Throat □Seasonal Allergies

□Depression □Bi-Polar □Anxiety □Insomnia □Hot Flashes □Abnormal Thirst □Diabetes □Hepatitis □HIV/AIDS □Blood Transfusions □Cancer ______

Family Medical History: Office Personnel Only

Heart Disease □

Diabetes □

Cancer □

Psychiatric □

Birth Defects □

Other (please describe): □

______

Personal Health Habits

Yes No

Smoking □ □ Cigarettes per day:______Years:______

Alcohol □ □ Drinks per day:______Drinks per week:______Occasional______

Drug Use □ □ Type:______Date Last Used:______

Birth Control History:

□Tubal □Condoms /Spermacide □ Vasectomy □ IUD/Hormonal IUD □ Nuva Ring □ Depo-provera

□ Diaphragm □ Oral Contraceptive □ Other ______

Current Contraceptive Method: ______Start Date:______

Pregnancies: ______Miscarriages:______Abortions:______Tubal/Ectopic Pregnancies:______C/Section ______

NOTES

Ob/Gyn History

LMP ______Age periods began ______

Are Your Periods Regular ? □ Yes □ No ______

How many days do you bleed? ______Cycle Length _____ Is the flow □ Light □ Medium □ Heavy

Do you have □ Premenstrual tension/PMS □Bloating □Cyclic Headaches □Nausea

□ Breast Discomfort □ Blood Clots □Cyclic Acne

□ cramps abdominal / low back If yes: □Mild □Moderate □Severe

What Treatment Do You Use For Cramps? □Over the Counter □Prescription □ Herbal □Hot Pack

Genitourinary: □ Yeast Infections □ B/V □ Vaginal Discomfort/Pain □Uterine Fibroids □Ovarian Cysts

Date of Last Pap: ______ Have you had: □ Abnormal Pap □ Colposcopy □ Leep

□ other:______

Breasts: □Fibrocystic Breasts □ Breast Cancer □ Implants □ Other ______

STDs: □Chlamydia______□HIV______□Herpes______□Genital Warts______

□Gonorrhea______□Trichomonas______□Syphilis______□ Other:______

Please list all medications you are currently taken & any you have taken in the last 30 days

MEDICATION
/ DOSE / HOW OFTEN / REASON / START DATE / STOP DATE
Sample:
Extra Strength Tylenol / Two tabs/
500mg / As needed / Headache / 5/30/08 / 5/31/08
Sample:
Vitamins / 1 tab / daily / Dietary supplement / 2000 / Cont.

______

Patient Signature Date

______

Coordinator Signature Date PI/Sub I Signature Date