Medical History Form (Page 2 of 4) in pdf

List any medications or substances you are allergic to, and what reaction each one caused, (e.g. “rash”):

______________________________________________________________________________________

List any medications, (prescription or over-the-counter), including vitamins and supplements you are taking now:

_____________________________________________________________________________________________

_________________________________________________________________

Family History:

Please list any health problems in members of your immediate family:

Mother: ______________________________________________________________________________

Father: _______________________________________________________________________________

Sister(s): _____________________________________________________________________________

Brother(s): ____________________________________________________________________________

Children: _____________________________________________________________________________

In your more extended family (aunts/uncles, grand-parents), has anyone had any of the following cancers? If so,

how are they related to you (e.g. grandmother on my dad’s side)?

Breast cancer? ________________________________________________________________________

Ovarian cancer? _______________________________________________________________________

Colon cancer? _________________________________________________________________________

Do either of your parents have osteoporosis? _______________________________________________

Has either your mom or dad ever had a broken hip? __________________________________________

Gynecologic History

Have you ever had any of these female problems? Please circle and give details for any “yes” answers:

Fibroids

Endometriosis

Ovarian cysts

Infertility

Polycystic Ovary Syndrome (PCOS)

Urinary incontinence

Heavy, prolonged, or irregular menstrual bleeding

Pelvic Pain

PMS

Breast problems or breast biopsies

Have you ever had an abnormal Pap? Yes/ No When? _____________

Did you receive any treatment for this? Yes/ No

If “Yes,” what treatment was done? (Freezing, laser, LEEP, cone biopsy.)

Did your Paps go back to normal after the treatment? Yes/No

Have you received the vaccine for HPV (Gardasil or Cervarix)? Yes/ No

Medical History Form Page 2