Medical History Form
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1
2Midwest Center for Women’s HealthCare
Medical History Form
DATE ___________________
NAME ________________________________________________ DATE OF BIRTH _____________________
OCCUPATION _______________________________Primary Care Physician (name & number) _____________________________________
WHO REFFERED YOU? ___________________________________________
The following information will assist us in providing you the most excellent care. This information is a confidential record. Please fill out both sides
of this form completely.
Have you ever had the following (circle all that apply)
Abnormal MMG
DVT/PE
High Blood Pressure
Ovarian Cyst
Abnormal Pap
Endometriosis
HIV/AIDS
Painful Periods
Anemia
Epilepsy
Irregular Vaginal Bleeding
Problem With Anesthesia
Arthritis
Fibroids-Uterus
Irritable Bowel/Colon
STD – History of
Asthma/Emphysema
Frequent Bladder Infections
Kidney Disease
Stroke
Blood Transfusion
Genetic Disorder
Liver Disorder
Thyroid - Low (Hypothyroid)
Cancer
GERD
Lupus
Thyroid - High (Hyperthyroid)
Clotting Disorder
Headaches/Migraines
Mitral Valve Prolapse
Vaginal Infections
Depression
Heart Disease
Osteopenia
Other:
Diabetes (Type I or Type II)
High Cholesterol
Osteoporosis
Your most recent:
Date
Result
Your most recent:
Date
Result
Mammogram
Cholesterol Check
PAP smear
Bone Density Scan
Colonoscopy
List all Surgeries and Procedures
Surgery/Procedure
Year Performed
Surgery/Procedure
Year Performed
List all prescription and over-the-counter medications and supplements you take regularly
Medication
Dose
Frequency (how often)
Prescribing Physician (or over the counter)
List all medication allergies and the reaction you have if you take them
Allergic To:
Reaction
Allergic To:
Reaction
Family History
Are You Adopted?
NO
YES—if blood relative history unknown, proceed to page 2
Has any blood relative had any of the following? Indicate “M” for maternal, “P” for paternal family member ( i.e. if your Mother’s mother, write MGM)
Problem
Family Member** Please List**
Age
Problem
Family Member
Age
Onset
Onset
Anemia
Epilepsy
Asthma
Heart Disease
Blood Disorder
High Cholesterol
Cancer – Breast
Hypertension
Cancer – Colon
Kidney Disease
Cancer – Ovarian
Migraines
Cancer – Uterine
Stroke
Cancer – Other
Thyroid Disorder
Depression
Diabetes, Type 1
Other
Diabetes, Type II
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Parent category: Medical