Medical History Form
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- Dale Thornton
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1 Compassionate Care for Women Medical History Form Date First Name Maiden/Middle Name Last Name Date of Birth How did you learn about Brandon Gynecology Associates, PA? Past OB/Gyn History Last menstrual period Prior menstrual period Regular menses? Yes No Heavy menses? Yes No # of pads # of tampons Painful menses? Mild Moderate Severe How do you treat menstrual pain? Irregular menses? Please explain Age of first menses Age of first intercourse Age of menopause (no menses for at least one year) Have you ever taken Hormones? Yes No Types Dates How many pregnancies? How many live births? How many miscarriages? How many ectopic pregnancies? Any C-sections? Yes No How many living children? Ages Did you breast feed for at least 3 months? Yes No Any complications with pregnancies? If so, explain Are you sexually active? Yes No Do you have sex with Men Women Both Present birth control method (including vasectomy) Do you have pain with sex? Yes No Have you ever been abused? Yes No Sexually Physically Psychologically When did the abuse occur? Are you in a safe situation now? Yes No Mallard Crossing Medical Park Mallard Creek Road - Suite 101D Charlotte, NC O F [email protected]
2 Page 2 of 5 Have you ever had any of the sexually transmitted infections or diseases listed below? If so, please check the diagnosis and provide treatment dates. Chlamydia Genital Herpes Genital Warts Gonorrhea HIV/AIDS Hepatitis Human Papillomavirus (HPV) Pelvic Inflammatory Disease (PID) Syphilis Trichomoniasis Have you ever had any of the following gynecological conditions? If so, please check the condition and provide treatment dates. Abnormal Pap Smears Breast Cancer Cervical Cancer Chronic Pelvic Pain Endometrial Polyps Endometriosis Fibroids Fibrocystic Breast Disease Infertility Ovarian Cancer Ovarian Cysts or Tumors Painful Sex Uterine Cancer/Endometrial Cancer Vulva Cancer Gynecology Surgery If you have had any of the surgical procedures listed below, please indicate which ones and provide the date of the surgery and any complications that you may have had. Colposcopy Cone biopsy of Cervix Dilatation & Curettage (scraping the lining of the uterus) Ectopic (pregnancy in fallopian tubes) Endometrial Ablation Essure (sterilization) Gynecological Cancer Surgery Hysterectomy (removal of uterus) Abdominally Vaginally Laparoscopic Robotic Hysteroscopy Infertility Treatments IUD: Mirena Paraguard Laparoscopy (surgical exploration of pelvis by camera) LEEP (Electrosurgical biopsy of the cervix) Myomectomy (removal of fibroids) Oophorectomy (removal of ovaries) Right Left Both Ovarian Cystectomy Pelvic Support Surgery Polypectomy (removal of polyps) Cervical Uterine Tubal Ligation (sterilization) Uterine Artery Embolization (treatment for fibroids) Urinary Incontinence Surgery Vulva Biopsies
3 Page 3 of 5 Medical Conditions If you have had any of the following medical conditions, please indicate the diagnosis date and treatment. Autoimmune Lupus Rheumatoid Arthritis Cardiovascular Anemia (Iron Deficient, Sickle Cell, B12 deficiency) Dates of any blood transfusions Bleeding disorders Deep Vein Thrombosis/Pulmonary Embolus Heart Disease High Blood Pressure Dermatological Eczema Skin Cancer/Melanoma Lichen Sclerosis/Lichen Planus Endocrine Diabetes Prolactinoma Thyroid Disease Gastrointestinal Colon Cancer Crohn s Disease Hiatal Hernia Inflammatory Bowel Disease Irritable Bowel Syndrome (IBS) Liver Disease (Hepatitis) Peptic Ulcer Disease Reflux Musculoskeletal Arthritis Ankylosing Spondylitis Degenerative Joint Disease Gout Inflammatory Arthritis Osteoporosis/Osteopenia Psoriatic Arthritis Rheumatoid Arthritis Neurological Alzheimer s Disease Cerebral Palsy Dementia Migraine Headaches Multiple Sclerosis Muscular Dystrophy Parkinson s Disease Seizure Disorder Date of last seizure Strokes Psychiatric Anxiety Bipolar Disorder Insomnia Major Depression Post Partum Depression Premenstrual Syndrome/PMDD Psychiatric Admissions Substance Abuse
4 Page 4 of 5 Respiratory Asthma Bronchitis Sleep Apnea Urological Kidney Malformation Kidney Stones Recurrent Bladder Infections Renal Transplant Nephritis Polycystic Kidneys Pyelonephritis (history of kidney infection) Medications Please list any medication allergies and type of reaction. Please list all medications (prescribed, over the counter, herbal and natural preparations). Are you on any blood thinners? Yes No Name of medication Any psychiatric medications? Yes No Name of medication Surgical History If you have had any of the following surgeries, please indicate dates and complications, if any. Appendectomy Back Surgeries Breast Reduction or Augmentation Cholecystectomy (removal of Gallbladder) Hernia Repair LASIK Eye Surgery Plastic/Cosmetic Surgery Tonsillectomy List any other surgeries with dates and complications.
5 Page 5 of 5 Social / Relational History Do you smoke? Yes No # of packs per week # of years Do you drink alcohol? Yes No # of drinks per week Do you exercise? Yes No Type # of hours per week Any occupational hazards? Yes No Type Do you practice a particular faith regularly? Yes No Type of Faith What is your marital status? Single and never married Married Widowed Divorced Domestic Partner Committed, long-term relationship Who are the members of your household? Family Medical History Please list any medical conditions in the family. Mother Father Daughters Sons Sisters Brothers Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Maternal Aunts/Uncles Paternal Aunts/Uncles Cousins Review of Symptoms Circle symptoms for today s visit only Breast Breast lump Breast pain Cardiac/Vascular Chest pain Heart palpitations Swelling of legs Varicose veins Ear, Nose, Throat, Mouth Head cold Sinusitis Sore throat Endocrine Thyroid problems Gastrointestinal Blood in stool Constipation Diarrhea Heartburn Hemorrhoids Nausea/Vomiting General Eye problems Fevers/aching Sudden weight loss/ gain Genitourinary Pain with urination Problem leaking urine Urine frequency Gynecology Hot flashes Irregular periods/no periods Night sweats Painful periods Pelvic pain STD exposure Vaginal discharge Hematologic Bruising Swollen glands Mental Health Anxiety Depression Mood swings Musculoskeletal Back pain/strain Leg/hip pain Muscle aches Respiratory Cough Shortness of breath Skin Abnormal mole Rashes/lesion
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