Patient History Information Form Page 2
ADVERTISEMENT
1
2
3
4Allergies:
Please list all known allergies and reactions, including medications, foods, or environmental agents.
Family Medical History:
Has anyone in your family ever had any of the following conditions? If so, please circle and write details in the right column:
CONDITION:
RELATION TO YOU/ DETAILS:
Diabetes
Heart Disease
High Blood Pressure
Uterine or Genital Cancer
Breast Cancer
Colon Cancer
Prostate Cancer
Bleeding Problems
Multiple Births (twins, triplets)
Birth Defects
Genetic Diseases
Osteoporosis
Blood Clots or Deep Vein
Thrombosis
OTHER:
Reproductive History:
First day of last menstrual period: ________________________ Your age at first period: _____________________________
Usual interval between periods: __________________________ How long do your periods last: ________________________
Do you have pain with your periods?
YES
NO
Is there any bleeding between your periods?
YES
NO
Have you ever had a pelvic infection?
YES
NO
Have your ever had an abnormal pap smear?
YES
NO
Have you ever had genital warts?
YES
NO
Have you ever had genital herpes?
YES
NO
If your answer is “YES” to any of the above questions, please describe below:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Do you currently use any method of birth control/pregnancy prevention? ________ Type:_______________________________
List other methods you have used: __________________________________________________________________________
Pregnancy History:
Total # of Pregnancies:
# of Miscarriages:
# of Abortions:
# of Deliveries:
Living Children:
Date
Gender
Name
Birth Weight
Anesthesia?
Pregnancy/Labor Details?
Location
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical