Adult Medical History Form Page 3
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36. Operations
Have you had any operations? If yes, list:
Type of operation / Reason for operation
Hospital / Facility
Date of operation
___________________________________
____________________
_______________
___________________________________
____________________
_______________
___________________________________
____________________
_______________
___________________________________
____________________
_______________
___________________________________
____________________
_______________
___________________________________
____________________
_______________
___________________________________
____________________
_______________
7. For Women Only
Total # of pregnancies_____
# of deliveries_____
# of miscarriages_____
# of abortions_____
Age at start of menstrual period
_______
Date most recent menstruation began
_______
Usual length of menstrual period
_______ days
Date of last Pap smear
_______
Have you ever had an abnormal Pap smear?
Yes
No
If yes, give date and describe___________________________________________________________
Have you stopped having menstrual periods?
Yes
No If yes, when________________
Do you have regular problems with:
Irregular, painful, or heavy menstrual periods
Yes
No
Bleeding between periods or after menopause
Yes
No
Vaginal discharge, pain or itching
Yes
No
Hot flashes
Yes
No
Pain or lumps in breasts
Yes
No
Please return to:
Daryl R. Dutter, M.D., Inc.
Kent A. Hufford, M.D.
J. Jeffrey Daley, M.D.
PO BOX 210 ∙ 150 VERA AVENUE
RIPON, CA 95366
PHONE (209) 599-4211 ∙ FAX (209) 599-7348
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