Patient Medical History Page 4
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5Gynecology:
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Age at first period:
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day (date) of last period:
Describe Period: ⧠Light ⧠Normal ⧠Heavy
Frequency of period:
Length of period:
Current Contraceptive Method:
Are you in menopause? ⧠Yes ⧠No
Do you have concerns regarding your period? describe:
Date of last period:
Are you on hormone replacement therapy? ⧠Yes ⧠No
Obstetrics:
Number
Number
Total number of pregnancies
Abortions Induced
Full Term Births
Miscarriages
Pre-Term Births
Living Children
No.
Birth Date
#weeks at
Sex
Birth
Delivery
Complications Location of
delivery
Weight
Type
Delivery
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Social History
Are you currently sexually active? Yes No _____ If yes, what age did you become sexually active? _______
Current sexual partner (s) is/are: Male Female Male and Female_______
Have you had more than 5 sexual partners in a lifetime? Yes No If yes, how many?__________
Have you ever has any sexually transmitted diseases ?(STDs): Yes No
If yes, what kind? ______________________________________________________
Are you interested in STD screening? Yes No
Do you drink alcohol? Yes No If yes, Social Drinker Daily if yes, how many drinks per week? _______
Do you use recreational drugs? Yes No If yes, what kind? _____________
Do you use tobacco? Yes No If yes, Current every day _________ Current some days ________________
Former ______________ Never_____________
If current, how many cigarettes a day? _______________________ if an occasional smoker – please
describe:________________________
4.
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