Medical History Form (Page 2 of 2) in pdf

Gynecologic and Obstetric History

Name of Gynecologist (if you are seeing one): __________________________________

Age at onset of periods: ______ Frequency: ___________ Length of period: __________

Pregnancies: ______ Births: _______ Miscarriages: ______ Abortions: _____

Age of menopause: ____ Symptoms of menopause: _____________________________

Date of last period: __________ Method of birth control: _________________________

Do you take, or have you ever taken, hormone replacements or birth control pills? _____

Describe: _______________________________________________________________

Have you had other gynecologic problems? _____ Describe: _______________________

Last Mammogram: ________________________________________________________

Last Pap Smear: __________________________________________________________

Last DEXA (bone density) scan: _____________________________________________

Family History

Family

Living? Age Cause of

Other Illnesses

member

Death

Grandparents

Father

Mother

Siblings

Children

Prevention

Last Sigmoidoscopy or Colonoscopy: _________________________________________

Do you take aspirin regularly? ________ How much? ____________________________

Do you take calcium regularly? ________ How much? ___________________________

Last Flu shot (influenza): ___________________________________________________

Pneumonia shot (Pneumovax): ______________________________________________

Meningococcus Meningitis vaccine (Menomune): _______________________________

Last Tetanus shot: ________________________________________________________

Have you had the Hepatitis B series of shots? _____ When? _______________________

Do you have an Advance Directive, Living Will, etc.? ____ If so, we would like a copy

to keep in your medical record.

Do you have an organ donor card? ___________________________________________

Do you smoke? _____ How much? ___________________________________________

Do you drink alcohol? ______ How much? ____________________________________

Do you use any recreational drugs? ______ Which? _____________________________

What exercise do you do?__________________________________________________

Do you wear a seatbelt? ___________________________________________________

Do you wear sunscreen when out in the sun? _______________________

Version 8/15/02 KB

Medical History Form Page 2