New Patient Medical History Form (Page 2 of 5) in pdf

New Patient Medical History Form Page 2

Medications: Please list all medications that you are taking, including vitamins, herbals and supplements

Allergies:

Drug allergies: ▢ None

If yes, please list drug and reaction:

Food allergies:

Latex allergy? ▢ Yes

▢ No

Gynecologic History:

Age at first menses:

▢ Yes ▢ No

Regular cycles?

Number of days between cycles: ______

First day of last menstrual period: _____

Length of flow: ________days

Bleeding between cycles? ▢ Yes

▢ No

Please check any that may apply:

Endometriosis

Fibroids

Infertility

Pelvic Pain

Ovarian Cysts

Polyps

Polycystic ovaries

Heavy periods

Ovarian cancer

Uterine cancer

Painful periods

Others:

History of abnormal Pap smears? ▢ Yes

▢ No

If yes, please check the therapy that you received:

Repeat pap

Colposcopy

LEEP

Cryotherapy (freezing)

Are you currently sexually active? ▢ Yes

▢ No

If yes, with:

▢ Male

▢ Female

▢ Both

Age you became sexually active: _________

Number of lifetime partners: ____________

New Patient Medical History Form Page 2

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