University of North Carolina Wilmington ♦ Abrons Student Health Center

AHME History Form (Age <40)

Date_____/_____/ 20____Chart #______

Medical History:

Condition / Self / Family / Condition / Self / Family
Y / N / Y / N / Y / N / Y / N
1-Heart attack/disease / 14-Eating disorders
2-Stroke / 15-Suicide attempts
3-Blood clots / 16-Alcohol abuse
4-Migraines/headaches / 17-Other Drug abuse
5-Depression/anxiety / 18-Herpes
6-Acne / 19-Chlamydia
7-Thyroid disease / 20-Gonorrhea
8-Breast lumps/disease / 21-Hepatitis
9-High blood pressure / 22-Trichomonas
10-Lupus / 23-HIV/AIDS
11-Liver/gallbladder disease / 24-Syphilis
12-Anemia / 25-HPV/Warts
13-Cancer / 26-Other

Please explain any positive responses:

If you have headaches, are they ever associated with visual changes, blurring, or other unusual sensations? Y/N

Have you been diagnosed with any medical conditions or been hospitalized? Y/N

Do you take any medicines? Y/N

Do you take any over-the-counter (OTC) medicines or supplements? Y/N

Do you have any drug allergies? Y/N______Ever had your cholesterol checked? Y / N

GYN History:

Date of last menstrual period: Do you check your breasts regularly? Y / N

Do you have any problems with your periods? Y / N If yes, explain

Ever had intercourse? Y / N When was the last time?

Type of sex? Vaginal / Oral / AnalPartners? Men / Women / Both

How many partners have you had in the past 6 months?______Lifetime?______

Have you had the gardasil vaccine? Y/ NInterested / Not interested

If yes, how many doses? 1 / 2 / 3Did you complete it before your first sexual experience? Y / N

Ever been pregnant? Y / N / Possible If yes, when? ______Outcome?

Ever had a pap smear? Y / N Date: ______Results:

Ever had an abnormal pap smear? Y / N Details:

Are you having any unusual vaginal discharge? Y / NAny pain and/or bleeding with intercourse? Y / N

Social History:

Alcohol: _____ drinks/week Age started_____ Tobacco: _____cigs/day Age started _____

Recreational drug use: ______Age started: _____

Do you exercise? Y / N______hours______days/week

How is your diet?______Do you restrict your food intake in any way?

Sexual assault/abuse: Past/ Present / NoPhysical abuse: Past/ Present / No

Childhood physical or sexual abuse: Y / N

If yes to any of the above 3 questions, do you want to discuss? Y / N

Contraceptive History:

Method / Now / Past / Problems
Condoms
Birth control pills
Nuva Ring
Depo Provera
IUD
Implanon
Withdrawal (pulling out)
Other

What method of birth control would you like to use?

Review of Systems: Circle any that have been present for more than 4 weeks.

General:Unexplained weight loss or gain, fatigue, fevers, night sweats

Skin:Changes in existing moles, unusual looking new moles, poorly healing wounds, rashes

Head/Neck:Blurred vision, double vision, sores in mouth

Cardiac:Chest pain, racing or irregular heart beat

Pulmonary:Cough, wheeze, shortness of breath with activity

GI:diarrhea, constipation, change in bowel habits, blood in stool, black stools, abdominal pain

GU: pain with urination, blood in urine, frequent UTIs, vaginal discharge, pain with sex, genital bumps

Breasts:Pain in breast, lumps, nipple discharge

M/S:Unexplained muscle or joint pain, swelling, limitations in normal activities

Neuro:frequent headaches, fainting, blackouts, seizures weakness, numbness, tingling

Psych:depression, anxiety, mood swings, feeling persistently down in the dumps, thought of suicide

Student Signature______Date______

____Provider Reviewed

SHC 03/12