New Patient Obstetrics & Gynecology Form Page 2
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1
2Obstetrical History:
Please record the number of:
Pregnancies
Vaginal Births
Ectopics
Abortions
Living Children
C-Sections
Miscarriages
List any complications of pregnancies
Medical History:
Please check if you or a blood-relative have had any of the following:
MYSELF FAMILY
MYSELF FAMILY
MYSELF FAMILY
Anemia
Mental Illness
Liver Disease / Hepatitis
High Blood Pressure
Depression
Gall Bladder Disease
High Cholesterol
Anxiety
Blood clots in veins/lungs
Heart Disease
Eating disorder
Blood Transfusion
Stroke
Migraine Headaches
Breast Cancer
Diabetes
Urinary Tract Infection
Colon Cancer
COPD / Emphysema
Lupus
Uterine Cancer
Asthma
Arthritis
Ovarian Cancer
Seizures
Back Injury
Other Cancer, specify:
Thyroid problems
Osteoporosis
Other Medical Problems (list all):
Surgical History:
Please list any operations, including the year, or your age when you had it:
Personal / Social History:
Occupation_____________________________________
Marital
Status________________________________
Do / Did you use tobacco products?
Yes
No
How much?
Do / Did you drink alcohol?
Yes
No
How many drinks per week?
Do / Did you use illicit/street drugs?
Yes
No
Which drugs?
Have you ever been tested for HIV?
Yes
No
Year and result:
Have you ever been a victim of physical, verbal, emotional or sexual abuse?
Yes
No
Medications:
Please list any medications you take, including over-the-counter medicines
MEDICINE
DOSE
HOW OFTEN
MEDICINE
DOSE
HOW OFTEN
Please list any allergies to medications:
Current Medical Concerns:
Please circle if you have had any of the following this week:
Weight change
Yes
No
Nausea / Vomiting
Yes
No
Trouble sleeping
Yes
No
Abnormal bleeding
Yes
No
Bowel changes
Yes
No
Night sweats / Hot flashes
Yes
No
Abnormal hair growth
Yes
No
Anxiety / Panic
Yes
No
Breast problems
Yes
No
Problems with urination
Yes
No
Depression
Yes
No
How did you hear about
us?__________________________________________________________________________________
Is there any other information you feel we should have?
Patient Signature
Date
Provider Signature
Date
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Parent category: Medical