W.g. History Form
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2Williamson Gynecology
Cile H Williamson, MD
Name: ________________________________
Age: ____
Date: ______
Marital Status: M S W D
Family Physician: _______________________________________________________________________________
Who may we thank for this referral? ________________________________Occupation_____________________
Reason for your visit today? ______________________________________________________________________
GYNECOLOGIC HISTORY
When was your last menstrual period? ___________
Periods: Regular
Irregular
What is the number of days you flow? ___________
Pain or cramps? Mild Moderate Severe
Present method of birth control ________________
Age when you had your first period? _________
Any prior sexually transmitted disease exposure? (STD) ____________________________________________
Have you ever had an abnormal pap smear? Yes No Treatment: Leep Laser Cryosurgery(Freezing) Conization
List any breast problems, breast surgery or biopsies: ______________________________________________
OBSTETRICAL HISTORY
Total # of pregnancies: ____________ Number of miscarriages: ______
# of vaginal births: _______________ # of cesarean births __________
List birth weight (s) of your child/children: ____________________________ Did you breastfeed: ___________
Any serious complications during your pregnancy or births? ___________________________________________
PAST MEDICAL HISTORY (Circle any of the following that you have had IN THE PAST)
Cancer(Type) _____________________________________________
Thyroid
Tuberculosis
Pneumonia
Hiatal Hernia
Rheumatic fever
Other _________
Blood Clot
Epilepsy
Jaundice
Asthma
High Blood Pressure
______________
Diabetes
Anemia
Hepatitis
Heart Trouble
Bleeding Tendencies
______________
Kidney Disease
Stroke
Arthritis
Heart Murmur
Irritable Bowel Syndrome
OPERATIONS: List type of surgery, doctor and date
FAMILY HISTORY (Circle the following that have occurred in your immediate family)
Breast cancer
Hypertension
Heart attack
Heart disease
Living
Cause of Death
Colon Cancer
Stroke
Epilepsy
Bleeding disorders Mother__________
__________
Uterine Cancer
Thyroid
Diabetes
Kidney Disease
Father __________
__________
Ovarian Cancer
Lung Disease
Osteoporosis
Siblings _________ _
__________
Siblings _________ _
__________
PLEASE TURN OVER AND COMPLETE FORM
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