Patient Medical Information Check In Sheet - Aoa Arizona Page 2

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Name
__________________________________
(Last, First, M.I.)
Pregnancy History
Total Pregnancies___________
Deliveries _____________
Miscarriages _______________
Abortions _____________
Date of delivery
Number of Weeks
Vaginal or C-Section or Miscarriage or Abortion
Baby’s Weight at Delivery
Personal Health
Have you ever been hospitalized? Yes No If yes, for what?
History
_______________________________________________________________________________________________
Have you ever had:
Date Diagnosed
Date Diagnosed
Heart Attack
Yes No
Syphilis
Yes No
Heart Murmur
Yes No
Cancer
Yes No
Stroke
Yes No
Scarlet Fever
Yes No
Diabetes
Yes No
Thyroid Disease
Yes No
Anemia
Yes No
Gonorrhea
Yes No
High Blood Pressure
Yes No
Chlamydia
Yes No
Rheumatic Fever
Yes No
HPV
Yes No
Asthma
Yes No
Chicken Pox Yes No
Genital Herpes □Yes □No
Blood Clots
Yes No
Other:________________________________
Do you have any Non Drug allergies?
If yes,
Yes No
what?___________________________________________________________________________________
Social History
Marital Status
Married Single Divorced Widowed
Occupation __________________
Ethnic Background _______________________
Are you sexually active? Yes No
Monogamous? Yes No
Sexual Preference Male Female
Do you smoke? Yes No
Do you drink Alcohol? Yes No
Do you use caffeine? Yes No
If yes
cigarettes
cigars
If so, how many per week? ______________________
If so, how many cups/drinks per
Other_______________________________
How many years? _____________________________
day? ______________________
If so, how many per day?_______________
How many years? ___________________
Do you exercise?
Yes No
How many times/week?__________________
What
Have you ever used street drugs? Yes No
drugs?____________________________________
Intravenous drugs? Yes No
Have you ever been abused? Yes No
Do you feel threatened now? Yes No
Other/Comments:
rev2/9/12

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