Medical History Form Page 4
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4Central Texas Surgical Associates
CURRENT SYMPTOMS CONTINUED
Genitourinary
Hematologic/Lymphatic
Frequent urination
no yes
Slow to heal after cuts
no
yes
Burning or painful urination
no yes
Easily bruise or bleed
no
yes
Blood in urine
no yes
Anemia
no
yes
Change in force or strain with urination
no yes
Phlebitis
no
yes
Incontinence or dribbling
no yes
Transfusion
no
yes
Kidney stones
no yes
Swollen glands
no
yes
Sexual difficulty
no yes
Painful periods
no yes
Irregular periods
no yes
Vaginal discharge
no yes
Breast Patient History
How many children have you had? _____
Your age when first child born? _____
Did you breastfeed?_____
Age at first menstrual cycle? _____
Age at last menstrual cycle (if menopausal)? _____
Date of last menses? _____
Number of prior breast biopsies _____
Have you had a hysterectomy? _____
Breast implants? _____
Do you take hormone replacement therapy? _____
How many years? _____
Do you do regular breast self exams? _____
List family members with breast or ovarian cancer and their relationship to you:
__________________________________________________________________
__________________________________________________________________
Patient Signature: _________________________________Date: ________________
Surgeon Signature: ________________________________Date: ________________
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