Patient Medical History
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5Women’s Health Care Group of PA
Patient Medical History
Please complete the following information as accurately as possible. Your answers on this form will help your
provider understand your medical concerns and conditions better. If you cannot remember specific details, please
give best estimates. We realize that this a very lengthy form, but we are asking you to provide a comprehensive
history for our Electronic Medical Record which results in improved care for you.
Name: ______________________________________________DOB:_____________Date:_______________________
Marital Status: Single Married Widowed Divorced Domestic Partner SS#___________________
Address: ___________________________________City:_______________________State:______Zip:_____________
Home Phone: ______________________Work Phone: __________________Cell Phone: _______________________
Emergency Contact Name: ______________________________Emergency Contact Phone: ____________________
Race: American Indian/Alaska Native Asian Black/African American Native Hawaiian/Pacific Islander
Other Race White Unknown Declined
Ethnicity: Hispanic or Latino Non-Hispanic or Latino Unknown Declined
Preferred Method Of Communication: Phone Mail E-mail Text
Email:___________________________________________________________________
Primary Care Physician: ________________________Phone:__________________Fax:________________________
Pharmacy Name: ___________________________________Phone:__________________Fax:___________________
Reason for Visit:
What is the reason for your visit: Annual exam Obstetric first visit Gyn Problem
If you are here for a problem what are your concerns? __________________________________________________
_________________________________________________________________________________________________
Health Maintenance Screening Tests:
□Yes □No
□Normal
□Abnormal
Colonoscopy
If yes, date ___/___/___
Results:
□Yes □No
□Normal
□Abnormal
Dexa Scan
If yes, date ___/___/___
Results:
□Yes □No
□Normal
□Abnormal
Mammogram
If yes, date ___/___/___
Results:
Pap Smear History:
□Yes □No
□Normal
□Abnormal
Pap smear
If yes, date ___/___/___
Results:
□Yes □No
□Normal
□Abnormal
LEEP
If yes, date ___/___/___
Results:
□Yes □No
□Normal
□Abnormal
Colposcopy
If yes, date ___/___/___
Results:
□Yes □No
History of HPV?
If yes, date ___/___/___
□Yes □No
□Inj.1
□Inj.2
□Inj.3
Received HPV
If yes, date ___/___/___
vaccine?
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