Medical History Form

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Medical History Form
Today’s Date: _____________ Name: ________________________________ Date of Birth: __________________
Do You Think of Yourself as (circle): Heterosexual
Homosexual
Bisexual
Something Else
Unsure
Last Menstrual Period: ___________________
Any Irregular Bleeding: Yes
No
Has Your Uterus Been Remove: Yes
No
If Yes, For What Reason: _____________________________
Do You Still Have Ovaries:
Yes
No
Are You On Hormone Replacement Therapy:
Yes
No
Allergies to Medications, Environment, or Dyes (Please Include the Reaction to All Allergies):
_______________________________________________________________________________________________
Medications:
_________________________
___________________________
____________________________
What Are You Using For Birth Control: _______________________________________________________________
Did You Receive Gardasil (HPV vaccination):
Yes
No
Medical History: (Please Circle Any That Apply to YOUR Health):
Alcoholism
Arthritis
Asthma
Blood Clot/DVT/PE
Cancer
Chlamydia
Depression
DES Exposure Diabetes
Drug Addiction
Eating Disorder
Genital Warts
Gonorrhea
Headaches/Migraines Heart Disease
Hepatitis
Herpes
High Blood Pressure
High Cholesterol
HIV
Kidney Disease
Lupus
Mental Health Conditions
Osteoporosis
Seizures
Syphilis
Stroke
Thyroid Disease
If You Circled YES To Any Of The Above, Please Explain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Surgical History: (Please Indicate Type and Date):
_________________________
______________________________
_________________________
Family History: (Please Note The Family Member & Maternal (M) OR Paternal (P) When Appropriate):
Breast Cancer: _________________________________ Colon Cancer: ________________________________________
Diabetes: _____________________________________ Genetic Disorders: ____________________________________
Heart Disease: _________________________________ High Blood Pressure: ___________________________________
Kidney Disease: ________________________________ Lung Cancer: _________________________________________
Osteoporosis: __________________________________ Other Cancer: ________________________________________
Ovarian Cancer: _______________________________ Ovarian Cancer: _______________________________________
Stroke/DVT/Clotting/Bleeding Disorder: _________________________________________________________________
Thyroid Disease: _______________________________ Uterine Cancer: _______________________________________
Other: ____________________________________________________________________________________________
Pregnancy History:
Check If No Changes
Note The Date For The Following Tests, If Applicable:
Total Number of Pregnancies: _________
Mammogram: ________________________________
How Many Living Children: ____________
Miscarriages: __________
Colonoscopy: _________________________________
Abortions: _____________
Bone Density Scan: ____________________________
Preterm Delivery: Yes
No
Any Cesarean Sections: Yes
No
Any Complications with Pregnancies: Yes
No
Social History:
Do You Smoke: Yes
No
If Yes, Amount: ____________________________________
Do You Drink Alcohol: Yes
No
If Yes, Amount: ____________________________________
Any Drug Use: Yes
No
If Yes, Type & Amount: ______________________________
Do You Have Any History of Abuse: Yes No
If Yes, Type, Age, & By Whom: ________________________

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