Patient Health History Questionnaire Template
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Women's Health Partners, LLC
Patient Health History Questionnaire
0
Name:
Reason for your visit:
PAST MEDICAL HISTORY:
None
(Do you have or have you ever had):
Alzheimer's Disease
Depression
Lung Cancer
Anemia
Diabetes Mellitus
Migraine Headache
Anxiety Disorder
DVT (Venous embolism)
Mitral valve prolapse
Arthritis
Epilepsy
Myocardial Infarction
Asthma
Esophageal Reflux
Osteoporosis
Breast Cancer
Fibromyalgia
Ovarian Cancer
Cardiac Arrhythmia
Hepatitis (A, B, or C)
Skin Cancer
Cervical Cancer
Hernia
Stomach Cancer
Cholesterol, elevated
Hypertension
Stress Incontinence
Colon Cancer
Hyperthyroidism
Stroke (CVA)
Congestive Heart Disease
Hypothyroidism
Transient ischemic attack
COPD (Lung Disease)
Irritable bowel syndrome
Ulcer
Coronary Heart Disease
Kidney stone
Uterine Cancer
Comments:
None
PAST GYNECOLOGIC HISTORY:
(Do you have or have you ever had):
Abnormal PAP Smear
Dysmenorrhea
Menorrhagia (heavy menses)
Amenorrhea (no menses)
Dyspareunia (painful sex)
Ovarian cyst
Anovulation
Ectopic
Pelvic adhesions
Bartholin's gland cyst
Endometriosis
Pelvic inflammatory disease
Cervical Cancer
Fibroid uterus
PMS
Candidiasis (chronic yeast)
Gonorrhea
Polycystic ovaries (PCOS)
Chlamydia
Herpes Simplex (HSV)
Recurrent vaginitis
Condyloma Acuminatum
Hirsutism
Syphilis
Cystocele
Human Papilloma Virus
Trichomonas
(dropped bladder)
Cytomegalovirus disease
Hydrosalpinx
Uterine polyps
DES Exposure in utero
Incontinence
Uterine prolapse
Dysplasia (abnormal paps)
Infertility
Uterine scar tissue
Dysfunctional Bleeding
Irregular menses
Comments:
REPRODUCTIVE & MENSTRUAL HISTORY:
Total # of
# of premature
# of
# of
# of multiple
# of Full Term
# of ectopics
# living
pregnancies
pregnancies
terminations
miscarriages
births
Date of last menstrual period:
Certainty of last menstrual period:
Menopause status:
Home pregnancy test:
Method of birth control:
On hormone replacement:
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WHP HEALTH QUESTIONNAIRE rev. 04/15
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Parent category: Medical