Ob/gyn History Form printable pdf download

IHA DIVISION OF OB-GYN

REVIEW OF SYSTEMS

New Patient

NAME: ________________________________________________

AGE _________

Date of Birth: __________________________________________

What are the reasons for your visit today?

Do you have any of the following health problems now or in the past?

Yes

Explain

 Abuse (physical/emotional)

 Frequent Urination

 Anxiety or depression

 Gall bladder disease

 Asthma

 Headaches

 Back pain

 Hearing/vision problems

 Blood Clots

 Heart murmur

 Blood in Urine

 High blood pressure

 Bloody/dark stools

 Kidney disease

 Sexual concerns

 Cancer

 Chest Pain

 Shortness of breath

 Constipation

 Stroke

 Thyroid disease

 Convulsions

 Diabetes

 Ulcers/indigestion

Health Risk Factors:

Has anyone in your family

Yes No

had the following:

Who?

Do you?:

Do self breast exam?



Heart attack

_______________________________

Any changes?



Diabetes

_______________________________

High blood pressure

_______________________________

Exercise regularly?



Osteoporosis

_______________________________

Type_______ Freq________

Colon cancer

_______________________________

Smoke?

 Cigs/day ________



Breast cancer

_______________________________

Consume Alcohol?

 Drinks/wk _______



Uterine cancer

_______________________________

Use recreational drugs?



Ovarian cancer

_______________________________

Use sunscreen regularly?



Birth defects

_______________________________

Wear seat belts?



Other:

__________

_______________________________

Eat dairy products daily?

 Servings/day ____



Eat fruits & vegetables daily?



Do you have any Medication or Latex Allergies?

Follow a low-fat diet?



Take calcium supplements?



Medication

Reaction

Take vitamin supplements?



___________________________________________________

Menstrual History:

___________________________________________________

Age at first period____ First day of last period____ /____ /____

___________________________________________________

Cycle length: ____days Flow____days  heavy  mod  light

Please list your current medications, dose, and how often

Have you ever had any of the

you take them (include herbs, vitamins, and supplements):

following gyn history?

Explain

Medication

Dose

Frequency Taken

 Herpes

___________________________________________________

 Gonorrhea/Chlamydia

___________________________________________________

 Genital Warts

___________________________________________________

 Abnormal pap smear

___________________________________________________

 IUD in the past

___________________________________________________

 Current birth control method _________________________

___________________________________________________

Date of last pap smear _____ / ______ / _____

___________________________________________________

Date of last mammogram _____ / _____ / ______

Have you ever had prior Surgery?

Have you ever had any prior pregnancies?

Year

Procedure

Year

Type birth

Wt.

Complications

___________________________________________________

________________________________________

Signature:

Date: ____ / ____ / _____

1134  09/14

Ob/gyn History Form

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