Women'S Health History Form
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1University of Connecticut Student Health Service, Storrs CT
Women’s Clinic Health History
PATIENT NAME (PLEASE PRINT)
TODAY'S DATE AND TIME
PS#
DATE OF BIRTH
AGE
Semester Status
Cell Phone
School Address
School Phone
Home Address
Home Phone
1. ALLERGIES (Medications, foods, latex, etc)
PAP TEST HISTORY
None
Yes (Please list)
40. Have you ever had a regular GYN exam?
No
Yes Date of last exam _________
41. Have you ever had a PAP test?
No
Yes Date of last test __________________
42. Have you ever been evaluated or treated for an abnormal PAP test?
No
Yes
2. MEDICATIONS: (Include birth control pills,
43. CONTRACEPTION HISTORY (Check all that apply)
Not Applicable
herbal/vitamin/nutritional supplements)
Birth control pills
Abstinence
Condoms
Spermicides
Diaphragm
Sponge
Name of Pill(s) __________________
IUD Type & date inserted ________________
Dates used Pill __________________
OrthoEvra ______________________
Depo Provera
Nuva Ring ______________________
Date started _____________
Plan B last used__________________
Date Last Shot ___________
Sterilization
MEDICAL/GYN HISTORY
LIFESTYLE (Check all that apply)
(CHECK APPROPRIATE BOX)
FAMILY MEANS Mother Father Sister Brother
44.Alcohol
None
Yes, type & amount per week _______________________
Adopted - family history not known
45.Tobacco
None
Yes, type & amount per day _________________________
Have you or family members had
YOU FAMILY
Age started __________years old Quit Date ___________________
3.High cholesterol……………………….
…..
46.Caffeine drinks
None
Yes, amount per day ______________________________
4.Heart disease………………………….
.….
47.Street drugs
None
Yes, type & amount _______________________________
5.Rheumatic fever or heart murmur…..
48.Do you exercise regularly?
No
Yes, type & amount _______________________
6.High blood pressure………………….
…..
49.Do you practice SBE (Self breast examination)?
No
Yes
7.Blood clots…………………………….
…..
50.Do you take calcium and/or have adequate calcium in your diet?
No
Yes
8.Asthma………………………………...
51.Have you ever had any sexual activity?
No skip to # 62
Yes,
answer all questions
9.Diabetes……………………………….
…..
52.Do you have sex with
Men
Women
Both
10.Thyroid disease……………………..
…..
53.Do you have
Oral sex
Anal sex
Vaginal intercourse
11.Liver disease………………………...
54.How old were you when you first had any kind of sex? __________years old
12.Hepatitis……………………………...
…..
55.About how many sexual partners have you had? __________
13.Anemia or blood diseases………….
56.Is sex painful for you?
No
Yes
14.Blood transfusion……………………
57.Do you practice safer sex?
No
Yes
15.Stomach/bowel/gallbladder disease
58.Do you practice withdrawal (he pulls out) without any contraception?
No
Yes
16.Kidney or bladder problems/UTI…..
59.Have you had a new sexual partner in the last 3 months?
No
Yes
17.HIV or AIDS………………………….
…..
60.When was your last sexual contact or intercourse? ________________________
18.Mononucleosis………..……………..
61.Are you in a relationship where you feel threatened?
No
Yes
19.Cancer………………….…………….
..…
62.First day of last period ____/____/____
20.Birth defects or inherited disease …
21.Epilepsy or convulsions…………….
63. MENSTRUAL HISTORY: (Before you started using Birth Control)
22.Migraines…………………………….
.….
Age at first period: _________years old.
23.Depression…………………………..
..…
Number of days between periods:________days
Length of periods: __________ days
24.Other psychiatric disorders…………
…..
Problems:
Heavy bleeding
Long periods
Significant pain
Irregular cycles
25.Eating disorder (anorexia/bulimia)...
64. PRESENT SYMPTOMS: Do you have any vaginal symptoms now?
No
Yes
26.Breast problems…………………….
…..
Unusual discharge
Itching
Burning
Pain
Foul Odor
Other ___________
27.Chlamydia……………………………
28.Gonorrhea……………………………
65. Do you have any concerns or want to talk about anything else?
No
Yes
29.Herpes………………………………..
66. Do you wish to have a chaperone in the room with you?
No
Yes
30.Syphilis…………………………...…..
31.Genital warts/HPV………………..…..
Patient Signature ______________________________________________________
32.Vaginal yeast infection………….…..
33.Bacterial vaginosis (BV)…….………
This area for health care provider use only.
34.Trichomonas………………….……..
35.Pelvic infections……………………..
36.Sexual abuse/assault/incest…….…
37.Physical abuse/assault………….….
NO KNOWN MEDICAL PROBLEMS
38. HOSPITALIZATIONS/SURGERIES:
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
39.PREGNANCY HISTORY:
Never Pregnant
# Pregnancies _________ # Deliveries ________
# Living children________ # Miscarriages _______
Clinician
# Abortion __________
Signature_____________________________________________________________
WC Health history rev 7/00, 6/05, 3/06
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