Medical History Form (Page 3 of 4) in pdf

Are you currently sexually active? Yes/ No

Have you had more than one sex partner in the past year? Yes/ No

Are you using contraception? Yes/ No

If “yes,” which method? (Circle on list below.)

Birth control pills Which brand? _____________________________________________________

Birth control patch (Ortho Evra)

Birth control ring (NuvaRing)

Birth control shot (Depo-Provera)

Mirena IUD When was it inserted? _____________________________________________

Paragard (copper) IUD When was it inserted? ___________________________________________

Condoms

Diaphragm

Tubal ligation

Essure

Partner has Vasectomy

Natural Family Planning

Implanon When was it inserted? ________________________________

Have you ever had any of these infections? Yes/ No (Circle any that apply and indicate when):

Chlamydia

Gonorrhea

Syphilis

HIV

HPV (Human Papilloma Virus)

Genital Herpes

Genital Warts

PID (Pelvic Inflammatory Disease or “tubal infection”)

(just skip any sections that don’t apply to you because of your age

Menstrual History

How old were you when you had your first period? ________

Describe your menstrual cycles (e.g. “about every 30 days, 5 days long, with 2 days heavy and the rest light, mild

cramps on heavy days):

_____________________________________________________________________________________________

_______________________________________________________________________________

______________________________________________________________________________________

If you are in menopause, at what age did your periods stop? _____________________________________

Are you having hot flashes or night sweats? none/ mild/ moderate/ severe (circle one)

Did you take hormone replacement therapy? Yes/ No

Are you having problems with vaginal dryness? Yes/ No

Painful intercourse? Yes/ No

Medical History Form Page 3