Patient Medical History Form Page 2
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513. Gynecologic History:
Pregnancies:
Number:
Dates:
Natural Delivery or C-Section (specify):
Menstrual: Onset:
Duration:
Are they regular: Yes
No
Pain associated:
Yes
No
Last menstrual period:
Hormone Replacement Therapy:
Yes
No
What:
Birth Control Pills:
Yes
No
Type:
Last Check Up:
14. Serious Injuries:
Yes
No
Specify (list all)
Date
15. Any Surgery:
Yes
No
Specify: (List all)
Date
16. Family History:
Age
Health
Disease
Cause of Death
Overweight?
Father:
Mother:
Brothers:
Sisters:
Has any blood relative ever had any of the following:
Glaucoma:
Yes No Who:
Asthma:
Yes No Who:
Epilepsy:
Yes No Who:
High Blood Pressure
Yes No Who:
Kidney Disease:
Yes No Who:
Diabetes:
Yes No Who:
Psychiatric Disorder
Yes No Who:
Heart Disease/Stroke
Yes No Who:
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