Gynecologic Health History
Name ______DOB ______Age ______Companion desired in room? o no o yes
Do you have any allergies to medications, metals, latex, rubber gloves, tape, shellfish, or antiseptic solutions (iodine/Hibiclens)? o no o yes
If yes please list allergy and reaction ______
Are you currently taking prescription medications, over-the-counter medications, vitamins or mineral supplements? o no o yes
If yes, list ______
How many hours/week do you exercise? ______Please list your work/hobbies/interests ______
MENSTRUAL HISTORY
When was the first day of your last normal period? ____/____/____ Age that you first started your period ______
Was your last period normal? o no o yes If no, explain ______
Do you have problems with your period? o no o yes If yes, explain ______
SEXUAL HISTORY
no / yeso / o / Have you ever had sexual intercourse? If yes, how old were you when you started? ______
Number of partners in the past year ____ In the past 60 days ____ Are/is your partner(s) o male o female o both o trans
o / o / Are you currently in a sexual relationship? If yes, sexual contact includes: o vaginal o anal o oral o sex toys
Date of last intercourse ____/____/____
Does your partner(s) have other partners? o no/unlikely o not sure/possibly o yes/definitely
o / o / Do you use condoms/barriers? If yes, how often? o sometimes o almost always o always
o / o / Have you recently felt pressured or been forced to have sex by anyone, including a friend, relative, date or partner?
SOCIAL HISTORY
no / yeso / o / Do you smoke cigarettes/cigars or chew tobacco? If yes, how many/much do you smoke/chew a day? ______
o / o / Do you drink alcohol? If yes, how often and how much? ______
o / o / Do you use street drugs? If yes, what and how often? ______
o / o / Have you ever had a partner who uses street drugs? If yes, what and how often? ______
o / o / Have you recently been physically or emotionally hurt by anyone, including a friend, relative, date or partner?
CONTRACEPTIVE HISTORY
What birth control method are you currently using, if any? ______
Any problems with this method? o no o yes If yes, explain ______
What methods have you used in the past? ______
Any problems with your previous methods? o no o yes If yes, explain ______
Have you had intercourse without birth control or condoms since your last period? o no o yes If yes, date ____/____/____
Are you interested in getting emergency contraception today, for use now or in the future? o no o yes
Are you interested in getting birth control today? o no o yes If yes, what kind? ______
PREGNANCY HISTORY (If you have never been pregnant please skip this section)
When did your last pregnancy end? ____/____/____ Are you breastfeeding right now? o no o yes
Please list the number of: Pregnancies ______Vaginal Deliveries ______C-sections ______Miscarriages ______Abortions ______Ectopic (tubal) ______
FAMILY HISTORY o I am adopted and don’t know my birth family’s medical history (Please skip this section)
Have any of your relatives been diagnosed with : (if yes please list relation)
no / yes / no / yeso / o / Heart Attack ______/ o / o / Cancer ______if yes, type? ______
o / o / Stroke ______/ o / o / Diabetes ______
o / o / Blood clots ______/ o / o / High Cholesterol ______
PAST MEDICAL HISTORY
Weight one year ago ______Lowest you have ever weighed (as an adult) ______
Month/year of last clinical breast exam ____/____ Month/year of last mammogram ____/____ Recommended follow-up? o no o yes
If yes, was follow-up completed? o no o yes If no, when is/was your next follow-up due? _____/_____
Month/year of last pap smear ____/____ Have you ever had an abnormal pap smear? o no o yes If yes, please give month/year ____/____
Did you complete the recommended follow-up? o no o yes If no, when is/was your next follow-up due? ____/____
Have you ever had any of the following (please complete both columns)
no / yes / no / yeso / o / Heart disease, heart attack or serious heart valve problem / o / o / Stroke
o / o / Blood clot(s) in veins or lungs, or blood clotting disorders / o / o / Seizures or epilepsy
o / o / Gall bladder removal or liver disease or liver tumors / o / o / Thyroid disease
o / o / Kidney disease or kidney failure or chronic adrenal failure / o / o / Lupus
o / o / Diabetes – If yes o insulin dependent o non-insulin dependent / o / o / Anemia
o / o / Severe long-term depression or other mental illness / o / o / Elevated blood pressure
o / o / Breast cancer or other cancer – if yes, what/when? ______/ o / o / High cholesterol
o / o / Herpes – if yes o oral o genital o Last outbreak ____/____/____ / o / o / Uterine abnormalities/fibroids
o / o / Genital warts
o / o / Chlamydia, gonorrhea, pelvic inflammatory disease (PID) or other STI – If yes, what/when? ______Were you treated? o no o yes
o / o / Migraine with aura or cerebral ischemia
o / o / Serious medical problems, illness, hospitalizations, recent surgeries, blood transfusions or exposure to blood products
If yes, explain ______
o / o / A medical problem being managed by another health care provider or any planned upcoming major surgeries
If yes, explain ______
Name/phone number of your medical provider ______
o / o / Vaccinations for o Hepatitis B o Rubella (measles, MMR) o Human Papillomavirus (HPV)
REVIEW OF SYMPTOMS
Current / Past / Nevero / o / o / General: Weight loss or gain of 20 lbs or more
o / o / o / Cardiovascular: Irregular heartbeat, severe chest pains not resolved with antacids
o / o / o / Neurological: Migraine with cerebral ischemia OR an increase or change in headaches
o / o / o / Endocrine: Excessive thirst or night sweats
o / o / o / Lymph: Painful or swollen glands in your groin
o / o / o / Gastrointestinal: Ongoing nausea or severe abdominal pain. If yes, how often? ______
o / o / o / Gastrointestinal: Severe, chronic constipation
o / o / o / Breast: Breast lump or nipple discharge. If yes, describe: ______
o / o / o / Respiratory: difficulty breathing with exercise
o / o / o / Psychosocial: Difficulty sleeping, eating, going to work or school for greater than 3 weeks
o / o / o / Genitourinary: Pain, burning or bleeding with urination
o / o / o / Genitourinary: Severe pain with periods that may include nausea, vomiting, or interfere with work or school
o / o / o / Genitourinary: Severe or persistent pelvic pain
o / o / o / Genitourinary: Abnormal vaginal discharge. If yes, describe: ______
o / o / o / Genitourinary: Pain with intercourse
o / o / o / Genitourinary: Itching or irritation of vaginal area
o / o / o / Skin: Rashes or lesions. If yes, describe: ______
o / o / o / Skin: Bumps, rash or sores on the genitals. If yes, describe ______
o / o / o / Mouth: Bumps or sores in the mouth. If yes, describe ______
o / o / o / Other: ______
Patient signature ______Date ______RN/Clinician signature ______
Downtown Women's Center, Inc. 511 SW 10th Ave. Ste. 905 Portland, OR 97205 503-224-3435