Name
Age
Date of Birth
Date
FEMALE MEDICAL HISTORY
This information is confidential and will be used by your medical provider to make sure you get proper care.
❏ Yes ❏ No
Are you allergic to any medications? List here:
❏ Yes ❏ No
Do you take any over the counter medicines, prescription medicines, vitamins, supplements, or home remedies?
List here:
❏ Yes ❏ No
Do you have a usual source of primary care? If yes, who?
A. Family Medical History:
Provider notes:
Has anyone in your family (mother, father, brother, sister) ever had:
1. ❏ Heart attack/disease
6. ❏ Diabetes
10. ❏ Maternal DES exposure
2. ❏ Stroke
7. ❏ Alcohol or drug abuse
11. ❏ Cancer
3. ❏ Blood clot in legs/lungs
8. ❏ Birth defects/genetic
12. ❏ I do not know my family
4. ❏ High blood pressure
problems
medical history
5. ❏ High cholesterol
9. ❏ Mental illness
B. Personal Medical History:
1. Have YOU ever had problems with any of these? Check all that apply.
A. ❏ Heart disease
K. ❏ Sickle cell disease
S. ❏ Gall bladder disease
B. ❏ High blood pressure
L. ❏ Kidney/bladder problems
T. ❏ Eating disorder
C. ❏ Stroke
M. ❏ Seizures or epilepsy
U. ❏ Cancer
D. ❏ Diabetes
N. ❏ Depression
Type: _______________
E. ❏ High cholesterol
O. ❏ Suicidal thoughts
V. ❏ Thyroid disease
F. ❏ Tuberculosis (TB)
P. ❏ Mental illness
W. ❏ Fibroids
G. ❏ Asthma
Q. ❏ Severe headaches or
X. ❏ Ovarian cyst/abnormality
H. ❏ Blood clot in legs/lungs
Y. ❏ Endometriosis
migraines
I. ❏ Bleed/bruise easily
R. ❏ Liver problems or
Z. ❏ Infertility
J. ❏ Anemia
hepatitis
2. ❏ Yes ❏ No Have you ever been hospitalized or had any surgery?
If yes, when and why? __________________________________________________
3. ❏ Yes ❏ No Have you ever had a transfusion or blood exposure?
4. ❏ Yes ❏ No Have you been immunized against rubella?
❏ I do not know
5. ❏ Yes ❏ No Have you been immunized against hepatitis B?
❏ I do not know
❏ I never had a Pap smear
6. When was your last Pap smear? _________________________
❏ Yes ❏ No Have you ever had an abnormal Pap smear?
If yes, when? ____________________________
7. ❏ Yes ❏ No Have you ever had an HIV test?
❏ Positive
❏ Negative?
If yes, when was your last one? ______________
Was it:
8. ❏ Yes ❏ No Have you ever had a mammogram?
If yes, when was your last one? ______________
Was it normal? _______________
C. Menstrual History:
1. Age period started: __________
2. Periods come every _________ days and last __________ days.
❏ Regular
❏ Irregular
❏ Painful
❏ Light
❏ Moderate
❏ Heavy
3. Periods are:
4. ❏ Yes ❏ No Do you have bleeding or spotting in between your periods?
D. Pregnancy History: (If you have never been pregnant, skip to next section)
1. Please list the number of the following: _____ Pregnancies
_____ Live births
_____ Abortions
_____ Miscarriages
_____ Ectopic (tubal) pregnancies
2. How long ago was your last pregnancy? _____ month(s), _____ year(s)
3. ❏ Yes ❏ No Are you currently breastfeeding?
April 2008