Indiana OB-GYN, PC
Swati Jain, M.D.
Initial Patient History Form
Please complete both sides of this form.
Patient Name ______Age ______DOB ______
Religion ______Marital Status ______
SSN# ______Primary Care Doctor ______
MEDICAL HISTORY
1. Reason for appointment ______
2. Have you or you family ever had any of the following conditions?
Self Your family M F GM GF etc
Yes No Yes No Who
o o a. Diabetes o o ______
o o b. High Blood Pressure o o ______
o o c. Epilepsy or Seizures o o ______
o o d. Frequent or Severe Headaches o o ______
o o e. Sickle Cell o o ______
o o f. Heart Disease/Heart Attack o o ______
o o g. Stroke o o ______
o o h. Cancer o o ______
3. Have you ever had any of the following conditions? If answer is yes, Please Explain
Yes No
o o a. Thyroid ______o o b. Breast Mass, Lump or Discharge ______
o o c. Asthma ______
o o d. TB or any type of Lung condition ______
o o e. Heart Murmurs ______
o o f. Rheumatic Fever ______
o o g. Stomach/Intestinal problems ______
o o h. Hepatitis/Mono or Liver problems ______
o o i. Gallbladder Disease ______
o o j. Chronic Bladder/Kidney infections ______
o o k. VD or STD, Gonorrhea, Syphilis, Herpes, Clap ______
o o l. Infection of the Uterus, Tubes, Ovaries ______
o o m. Frequent Vaginal infections ______
o o n. Tumors ______
o o o. Blood clots in veins ______
o o p. Varicose veins ______
o o q. Anemia ______
o o r. Rubella (German measles/3 day measles) ______
o o s. Immunizations (vaccinations) ______
o o t. Mental/Emotional problems ______
o o u. Other ______
4. Please list medications that you are taking, include herbal and over the counter
______
______
______
______
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5. Allergies: are you allergic to medication, food, other? ______
6. Do you use any of the following: How much?
o Cigarettes ______
o Alcohol ______
o Drugs ______
SURGERY HISTORY
7. Have you ever bee pregnant?
_____ Total # of times Pregnant, include this one _____ Number of Vaginal Births
_____ Number of Live Births _____ Number of C-Sections
_____ Number of Miscarriages _____ Number of Living Children
_____ Number of Elective abortions _____ Age at first pregnancy
8. Any complications with the delivery or pregnancy? ______
MENSTRUAL HISTORY
9. First date of last period ______
Age when you started your period ______
Number of days from one period to the next ______
Number of days your period last ______
Amount of flow: o Heavy o Medium o Light
Cramping: o None o Mild o Moderate o Severe
10. Do you have any of the following:
o Cramps o Discomfort before periods o Abnormal Vaginal Discharge
o Vaginal Sores o Spotting after intercourse o Painful Intercourse
o Vaginal odor, itching, swelling, burning
11. Have you had a mammogram? o Yes o No Last Mammogram ______
12. Date of Last Pap Smear ______o Normal o Abnormal Where: ______
If abnormal what type of treatment was used? ______
13. Do you use feminine hygiene products? ______
CONTRACEPTIVE HISTORY
14. What type of contraceptives do you use? ______
How long have you used this method? ______
Do you want to use another method? ______
Are you trying to get pregnant now? o es o No If yes, how long? ______
How may partners have you had? ______
How old were you when you first had sex ______
Please check all the methods you have used for contraception
o Withdrawal o Oral o IUD
o Condoms o Diaphragm o Foam, Jelly, Cream
o Rhythm o Natural Family Planning o Injection
oAbstinence o Vasectomy oTubes Tied
o Luck
Signature ______Date ______
Physician Signature ______Date ______Page 2of 2