Patient Medical History Form - Grand Traverse Women'S Clinic

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1200 Sixth St. Suite 400
Traverse City, MI 49684
Ph. 231-392-0650
Fax 231-392-0665
Patient Medical History Form
Name____________________________________ Date of Birth ___/ ____/___ Age______ Today’s Date______________
☐Single ☐Married ☐Separated ☐Divorced ☐Widowed Referred By: ________________________
**List any allergies & reactions to medications: _______________________________________________________________ OR
No Known Allergies
Medications
List medication and dosages you are currently taking, including over-the-counter medications, vitamins and herbal
remedies:
________________________ ___________________________ ________________________
________________________ ___________________________ ________________________
Family History
Please list any close relative (indicate maternal or paternal relationship) with a history of the following:
Relative/Age at diagnosis Relative
☐Breast Cancer
☐High Blood Pressure
☐Ovarian Cancer
☐Diabetes
☐Uterine Cancer
☐Heart Disease (heart
attacks, stroke, bypass surgery)
☐Colon Cancer
☐Osteoporosis
☐Sickle Cell
☐Cystic Fibrosis
☐Tay Sachs
Blood Clots
☐Muscular Dystrophy
☐Hemophilia
☐Other Genetic Disorder
Gyn History:
Age of first period________ Last menstrual period: _____________
Age of menopause________
Birth control:
Condoms
Vaginal ring
Partner with vasectomy
Patch
IUD
Pills
Tubal
Natural family planning
None
Other
Have you ever had any STD’s?
Yes
No If yes please list which ones: ________________________________________
Have you ever had an abnormal pap smear?
Yes
No
If yes, what treatment did you receive for it: _________________________________________________________________
OVER

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