Health History Form
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2Camelback Family Planning
Health History
Please print your full name here: __________________________________________________ Date: _______/________/_________
Date of birth: _____/______/______
Do you have any allergies to medications, metals, latex, rubber gloves, tape, shellfish, or antiseptic solutions (iodine/Hibiclens)?
NO
YES If yes, list allergy and reaction: ___________________________________________________________________
Have you ever had a bad reaction to anesthesia or sedation?
NO
YES
If yes, explain: _______________________________________________________________________________________________
Are you currently taking any medications, drugs, over-the-counter or herbal medications, vitamins or mineral supplements?
NO
YES If yes, list: _____________________________________________________________________________________
PAST MEDICAL HISTORY
Have you EVER had any of the following: (please complete BOTH columns)
No
Yes
No
Yes
Heart disease, heart attack or serious heart valve problem
Stroke
Pulmonary Embolism (PE) or Blood clotting disorders
Seizures or epilepsy
Bleeding problems
Bowel disease (e.g., IBS, Crohn’s)
Anemia
Thyroid disease
Elevated blood pressure
Bladder Infection
Long-term steroid medication use (e.g., prednisone)
Sickle Cell Disease
Uterine abnormalities/fibroids
Anxiety or Depression
Blood Transfusion
Genital herpes Last outbreak: _____/_____/______
Chlamydia, gonorrhea, pelvic inflammatory disease (PID) or other STI
Asthma, breathing problems, other lung disease (e.g., sleep apnea)/ Inhaler use
Kidney disease or kidney failure or chronic adrenal failure
Deep vein Thrombosis
Cancer – If yes, what? ____________________________________________
Serious medical problems, illness, hospitalizations, surgeries, blood transfusions or exposure to blood products
If yes, explain:______________________________________________________________________________________
A medical problem being managed by another health care provider or any planned upcoming major surgeries
If yes, explain: _____________________________________________________________________________
Name & Phone of Medical Provider ____________________________________________________________
SOCIAL HISTORY
No
Yes
Do you smoke cigarettes / cigars or chew tobacco? If yes, how many/much do you smoke/chew a day? _____________
Do you drink alcohol? If yes, how often and how much? ____________________________________________________
Have you ever used street or IV drugs or other substances?
If yes, list: _________________________________________________________________________________________
Reviewed by Clinic Staff: ____________
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Parent category: Medical