Patient History Form Today s Date / / Patient Name: Age: Date of Birth / / MRN # Patient Mailing Address: Hand Preference: Right Left Both Race/Ethnicity(Optional): Referring Physician and Address: Primary Care Provider / Practice: Reason for Visit: Please List ALL Current Medications and Supplements (include over the counter, non-prescription, prescription medications, hormonal birth control, vitamins, home remedies, and herbs): 1. 2. 3. 4. 5. 6. 7. 8. 9. Medication Name Dose of Medicine # times taken per day Do you have any allergies Yes No 1. 2. 3. If yes, please check all that apply: Anesthesia Codeine Penicillin Iodine Food Latex Morphine Sulfa Aspirin Bee Stings Other Allergies: Reaction: Have you ever had surgery? Yes No Please check/date year performed to all that apply. List any additional: Appendectomy Thyroid surgery Women s Section Only: Colonoscopy (year) Tonsillectomy Beast- lumpectomy Cosmetic surgery Bladder surgery Dental Breast- needle biopsy Gallbladder Breast- reduction Heart bypass surgery Breast-enlargement Heart stent Breast-excisional biopsy Heart surgery(other) Breast-mastectomy Heart valve replacement D&C Hemorrhoid surgery Endometrial ablation Hernia repair Hysterectomy, partial/total Lithotripsy(kidney stone) Laparoscopy Obesity Surgery (gastric bypass) Ovaries-removal of one/both Orthopedic surgery(back, knee, hip, etc) Tubal ligation Sinus surgery Urethral stretching
Have you or others in your immediate family (parents, grandparents, brothers, sisters, children, or grandchildren) had any of the following? (Please check all that apply): Condition Self Family Member (List Relation) Specify Type (if applicable) Abdominal Aneurysm Alzheimer s Disease Anemia Angina Anxiety Arthritis Bladder Disorder Blood Clots Blood Transfusion Breathing Difficulty Cancer Chronic Pain Colon Polyps Depression Diabetes Fibromyalgia Gerd Headaches/chronic Hearing Problems Heart Disease/Heart Attack High Blood Pressure High Cholesterol Infectious Disease (Hepatitis /HIV) Kidney Disease/stones Liver Disease Lung Disease/Asthma Lupus Memory Loss Menstrual problems Multiple Sclerosis Muscle Disease Osteoporosis Parkinson s Disease Psychiatric Condition Seizures Sleep Disorders Stomach Problems/ulcer Stroke Sudden Death Thyroid disorder Vascular Disease Vision problems/glaucoma 2
Family History: Relative Age, if living Health (Good or Bad) Age at Death Father Mother Sisters Brothers Do you smoke cigarettes? Do you drink alcohol? Have you used recreational drugs? Yes No If yes, how many packs per day? If yes, how many drinks per day? If yes, what type and when? What is your level of physical activity? Limited Moderate Highly Active-explain Do you follow a particular diet? Yes No What is your current occupation: No Gynecological Pregnancies (include all pregnancies, miscarriages, abortions, ectopic pregnancy, stillbirths) Include problems such as: premature, preterm labor, preeclampsia, gestational diabetes, etc.: Preg. Year # weeks Female Birth Cesarean/ Place of Doctor Problems pregnant at delivery /male weight vaginal delivery 1. 2. 3. 4. 5. 6. How old were you when you had your first menstrual period? First day of last menstrual period: Are your periods regular? Yes No/Explain: How long does your normal period last (first bleeding until last bleeding? (Number of days) How far apart are your periods (first day of period to the first day of next)? My menstrual flow is: Light Moderate Heavy Heavy with clots Cramping with my periods is: None Mild Moderate Severe Are you having bleeding between menstrual periods? Yes No Do you bleed after sex? Yes No If you have been through menopause, how old were you at that time? surgical Natural If you have gone through menopause, have you taken hormone therapy? Yes No 3
Pills Nuvaring Patch Implanon Depo-Provera(shot) Mirena IUD Paragard IUD Tubal/Vasectomy Current Birth Control Method Condoms Diaphragm/Cervical Cap Suppository, film, foam Withdrawal(pull out) Abstinence No method Trying to get pregnant Hysterectomy Have you had the vaccine series (Gardasil/Cervarix) for prevention of cervical cancer and genital warts?) yes No Are you sexually active? Yes No Not now but in past Plan to become active Do you have pain with intercourse? Yes No Do you have any sexual problems/concerns? Yes No When was your last pap smear? (for women over 21) (Year) Normal Abnormal When was your last mammogram?(for women over 40) Normal Abnormal Have you had a bone mineral density test (DEXA)? Yes No Did your mother take medication (DES) to prevent a miscarriage while pregnant with you? Yes No Have you been abused? physically Sexually Emotionally Have you had any of the following gynecological conditions- use space for all others: Infertility (trouble getting pregnant) Genital warts(hpv) Ovarian Cysts Endometriosis Chlamydia Uterine fibroids Colposcopy (for evaluation of abnormal pap smear) Gonorrhea Polycystic ovarian syndrome(pcos) Dysplasia(precancerous cells on cervix) Herpes Interstitial cystitis Cryosurgery for treatment of dysplasia Syphilis Urine leakage LEEP for treatment of dysplasia Pelvic inflammatory disease Do you lose urine when you cough or sneeze? Laser treatment for treatment of dysplasia Recurrent vaginal infections Recurrent bladder (UTI) infections (3x or more a year) 4
Review of Systems: Please check any of the SYMPTOMS below that you experience regularly and ARE NOT already being cared for by another physician: General Health Skin Vision Ear, Nose, Throat,Neck Yes No Yes No Yes No Yes No Overall Good Rashes Vision Change Hearing problem Health Appetite Change Bruising Dry Eyes Choking Fever Itching Blurred Vision Dry mouth Chills Mole Sore Eyes Swallowing problem Excessive Fatigue Acne Watery Eyes Ringing in ears Weight Loss/Gain Itchy Eyes Daytime Sleepiness Breast Heart Pulmonary Gastrointestinal Yes No Yes No Yes No Yes No Chest Pains Problem Constipation Lump Breathing Irregular Heartbeat Chronic Cough Incontinence Pain Rheumatic Fever Wheezing Nausea/Vomiting Nipple Discharge Heart Murmur Diarrhea Heat Attack Cong. Heart Failure Pacemaker Genitourinary Musculoskeletal Neurological Psychiatric Yes No Yes No Yes No Yes No Urinary Urgency Joint Pain Numbness Sad or Depressed Urinary Incontinence Back Pain Weakness Sleep Disturbance Pain Upon Muscle Aches Shaking Anxiety Urination Frequency Arthritis Difficulty Psychosis Walking/Sitting Speech Difficulty Suicidal Thoughts Headaches Difficulty Thinking Immune/Allergy Hematology Endocrine Yes No Yes No Yes No Itching Anemia Excessive Thirst Sneezing Frequent Bleeding Heat/Cold Intolerance Med. Allergy Frequent Bruising Hair growth/loss Arthritis Hot flashes Environmental Allergy Night sweats 5
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the physician of any changes in my medical status. / / / / Patient/Guardian Signature Date Physician Signature Date 6