Medical History Template

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MEDICAL HISTORY
_________________________________________________
Name:
Date of Birth: _____________
Past Medical History:
_______
Last Pap Smear Date:
Normal? □ No □ Yes Ever had an abnormal Pap Test? □ No □ Yes
__________________________________________________________________________________
_____
Last Mammogram Date:
Normal? □ No □ Yes Ever had an abnormal Mammo Test? □ No □ Yes
Have you had a Bone Density Scan? □ No □ Yes- date & result
_________________________________
Have you had a Colonoscopy? □ No □ Yes- date & result
●Specify/Check Any Problems you have had and the Date of Diagnosis:
_______________________________________________________________________
Pregnancy:
___________________________________________________
Gynecology: (Uterus, Cervix,Ovaries)
_________________________________________________________________________________
STD: □ HPV □ Trich
□ Chlamydia
□ Gonorrhea □ Herpes □ Hepatitis B or C □ HIV □ Syphilis
_____________________________________________________
Breasts: □ Cancer □ Mass □ Biopsy
_____________________________________________
Heart: □ High Blood Pressure
□ Heart Disease
____________________________________________
Digestive Disorders: □ Reflux □ IBS □ Cancer
________________________________________________
Endocrine: □ Diabetes
□ Thyroid Disease
_____________
Blood: □ Anemia □ Blood Transfusion □ Sickle Cell Trait or Disease □ Clotting Disorders
__________________________
Musculoskeletal: □ Arthritis □ Scoliosis □ Osteopenia or Osteoporosis
____________________________________________________
Neurological: □ Migraines □ Seizures
_______________________
Psychiatric: □ Anxiety □ Depression □ Suicide Attempt
□ Eating Disorder
__________________________________________
Respiratory: □ Asthma □ Tuberculosis test positive
_______________________________________________
Skin Disorders: □ Skin Cancer
□ Psoriasis
_____________________________________
Urology: □ Frequent Bladder Infections
□ Kidney Stone
_______________________________________________________________
Seasonal Allergies: □
Surgical History:
□ Tonsillectomy
□ Appendectomy
□ Gallbladder Removal
□ Bladder Surgery
□ Kidney Stones Removed □ Hernia Repair □ Thyroid Surgery □ C-Section □ Sterilization/Tubal Ligation
□ Hysterectomy with Removing Ovaries □ Ovary Cyst Aspirated or Removed □ Cervix Surgery
□ Colposcopy
□ CRYO Freezing
□ Laser or LEEP or Cone of Cervix □ Breast Reduction
□ Breast Augmentation
___________________________________________________________
□ Any Cancer Surgery □ Other:
**Please Include Approximate Dates for Surgeries- if you’ve had any type of hysterectomy state
type AND reason**
Social History:
Alcohol: □ None : □ Occasional □ 1-4 Drinks per week
□ 5 or more per week
_____________________________________________
Tobacco Use: □ No
□ Yes
How many a day:
Education Level: □ High School
□ GED
□ Diploma
□ College
□ Graduate Studies □ Post-Graduate
□ I am a Student now
Exercise: □ None
□ 1-3 x week
□ 4 or more x week
PLEASE TURN PAGE OVER AND FILL OUT BACK SIDE
MEDICAL HISTORY (Page 2)

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