Health History Form printable pdf download

Health History Form

Ob-Gyn Physicians, Inc.

Please fill in all information below

A Division of Mid-Atlantic Women’s Care, P.L.C.

J. Floyd Clingenpeel, MD

Sharon Sheffield, MD, FACOG

Tobi W. Byrd, WHNP, CNM

Name: __________________________ Date: ____________ Referred by: ____________________

Reason for visit: ____________________________________________________________________

Menstrual History

Gyn History

(If you are menopausal or have had a hysterectomy, skip to part III)

Have you had any of the following (check below)

abnormal Pap smear

First day of most recent period (date) _____________________

How many days between starts of periods _________________

cervical cryo or laser surgery

How long do your periods last ___________________________

condyloma/genital warts

Any problems with your periods?

Yes

endometriosis

Describe if yes ________________________________________

ovarian cysts/tumors

uterine fibroids

II Contraceptive History

pelvic inflammatory disease

Current contraception (include tubal or vasectomy) __________

other GYN problems

Name of birth control pill _______________________________

Describe above _______________________________________

Any problems with current method _______________________

____________________________________________________

Date of last Pap test ____________ Last pelvic _____________

Other past methods used _______________________________

Date of last mammogram (if over 35) _____________________

III Pregnancy History

List relatives with breast or ovarian cancer _________________

____ Total pregnancies

VI Current Medications (list):

____ Miscarriages

____________________________________________________

____ Abortions

____ Vaginal deliveries

____________________________________________________

____ Caesarian sections

VII Allergies (list) :

Describe any serious problems with pregnancies ____________

___________________________________________________

____________________________________________________

Are you currently trying to get pregnant

Yes

____________________________________________________

Past Medical History

Describe or enter comments

Anemia/blood disorders

Self