Personal Medical History Template (Page 3 of 4) in pdf

Medications

Please list the names and doses of all medications you take: _______________________________________

________________________________________________________________________________________

Allergies

Please list any medications you have allergies to and the reaction: __________________________________

________________________________________________________________________________________

Please list any food allergies you have and the reaction: __________________________________________

________________________________________________________________________________________

Are you allergic to latex? Yes/No

Are you allergic to iodine? Yes/No

Family Medical History

Do any of your family members have the medical problems listed below? If yes, please circle and give details

(relationship, age at diagnosis).

Breast cancer

High blood pressure

Ovarian cancer

Heart disease

Uterine cancer

Diabetes

Cervical cancer

Osteoporosis

Bowel (colon) cancer

Stroke

Blood clots in the legs or lungs

Thyroid problems

Please use the lines below for any medical problems not listed: _________________________________

_____________________________________________________________________________________

Reproductive History

How old were you when your periods started? ___________

How often do your menses occur? _____________________

How long do they last? ______________________________

Is the flow light, medium or heavy? ____________________

What methods do you use for contraception? __________________________________________________

How many times have you been pregnant? ______________

Have you ever had any miscarriages? Yes/No

If yes, how many? ________

Have you ever had an abortion? Yes/No

If yes, how many? ________

Have you ever had an ectopic pregnancy? Yes/No

If yes, please describe location and treatment:

________________________________________________________________________________________

Personal Medical History Template Page 3