Medical History Template (Page 2 of 2) in pdf

Relationship History

□ Single

□ Dating

□ Not Dating

□ Long-term partner

□ Engaged

□ Married

□ Separated

□ Divorced

□ Widowed □ Same Sex Relationship

Would you like to discuss Abuse (Emotional, Physical, or Sexual)?

□ Yes

□ No

□ No Abuse

Birth Control Methods: □ Condoms □ Birth Control Pills □ Nuva Ring □ Patch □ Depo Shot □ Diaphragm

□ Abstinence □ Rhythm / NFP □ Withdrawal □ IUD □ Tubes Tied □ Partner with Vasectomy □ Desire Pregnancy

Reproductive History:

Menstrual History: Age Menses First Started ___

_______

__________

First Day of Last Menstrual Period:

or Year of Last Period

(Menopause)

_____

Duration of Menses:

Interval = every

Days

Flow: □ Light

□ Medium

□ Heavy

Days Cycle □ Clots

_____

Pregnancy History: Total Number Pregnancies:

Currently Pregnant:□ No □ Yes Live Births:

_____

Full Term (37 weeks or more):

Premature (less than 37 weeks):

Miscarriages:

_____

Ectopic Pregnancies:

Voluntary Abortions:

Living Children:

Birth History: Please fill this in for each of your children if you are pre-menopausal from first birth to current

_________l_________l___________l________l____l_______________________l_________l_______

Family Medical History: □ Family History Unknown

□ Adopted

Use Abbreviations

**Include approximate age at which family member was diagnosed

M (Mother)

Heart Disease (Cardiac)

F (Father)

__________________________________

High Blood Pressure:

B (Brother)

________________________________________

Heart Attack:

S (Sister)

____________________________________________

Stroke:

MGM (Maternal Grandmother)

____________________________

Blood Clots in a Leg or Lung:

PGM (Paternal Grandmother)

__________________________

Endocrine Problems: Diabetes

MGF (Maternal Grandfather)

______________________________________

Thyroid Disease

PGF (Paternal Grandfather)

Cancer (Neoplasms)_Which kind? (Breast, Uterus, Ovary, Colon, Lung)

A (Aunt)

U (Uncle)

________________________________________________________________________________

________________________________

Genetic problems like, Sickle Cell Trait, Cystic Fibrosis, Other:

Medications: List ALL medications, doses, & reason for taking (include over the counter meds, supplements)

_________________________________________

____________________________________

_________________________________________

____________________________________

_________________________________________

____________________________________

_________________________________________

____________________________________

_________________________________________

____________________________________

_________________________________________

____________________________________

_________________________________________

____________________________________

Medication Allergies: □ None

List ALL medications that you are allergic to AND reaction you have

________________________________________________________________________________

___________________________________

□ Allergy to Penicillin □ Latex □ Iodine □ Other:

Immunizations:

Have you gotten the Gardasil® vaccine to prevent Human Papilloma Virus?

□ Yes □ No □ No, I am over 26 years old, □ No, but I am interested in more information

Medical History Template Page 2

Related Articles

Related forms

Related Categories