Pap Health History Form
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1PAP HEALTH HISTORY FORM
NAME_______________________________BIRTHDATE____________DATE____________
GYNECOLOGICAL HISTORY
1. _______ First day of your last menstrual period
2. _______ How many days does your period last?
3. _______ How many days between periods?
4. _______ Age when you started your period
5. _______ Do you currently have bleeding between periods?
6. _______ Do you currently have bleeding or pain during intercourse?
7. _______ Do you currently have any unusual vaginal itching, discharge or odor?
8. _______ Do you currently have pelvic pain?
9. _______ When was your last pap smear?
10. ______ Have you had an abnormal pap smear? If yes, explain _____________________________
11. ______ Do you do self breast exams?
12. ______ Have you had a mammogram?
13. ______ Have you had the HPV vaccine?
SEXUAL HISTORY
1. _______ Are you currently sexually active? If yes, with males, females, or both? _______________
2. _______ Age you first had intercourse
3. _______ Have you had contact with a bisexual male or IV drug user?
4. _______ Have you had more than one sexual partner since your last pap smear?
5. _______ Are you using contraception? If yes, what type? _________________________________
PREGNANCY HISTORY
1. _______ Number of living children
2. _______ Number of miscarriages
3. _______ Number of terminations
DISEASE AND INFECTIONS (Check any you have had)
Chlamydia
Gonorrhea
Herpes
Trichomonas
Genital Warts/HPV
HIV
Syphilis
Hepatitis
Other, __________________________________________________
SURGERIES (Check any you have had)
Colposcopy
Leep
Cervical Cryotherapy
Hysterectomy
D&C
Laparoscopy
Tubal ligation
Removal of tubes or ovaries
Other, _______________________________
MEDICATIONS
List all medication you are currently taking, including herbal medications and supplements:
__________________________________________________________________________________
MEDICAL HISTORY (Check any you have had)
High blood pressure
Heart disease
Blood clots in legs or lungs
Stroke
Migraines
Do you smoke?
Yes
No
FAMILY HISTORY (Check if any family members have had)
High blood pressure
Heart attack
Stroke
Blood clots
Cancer
PATIENT’S SIGNATURE____________________________________________DATE__________
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