The Healthy Woman

New Patient History

Name Age

What brings you to our office today?

Do you have any problems or concerns that you would like to discuss with us today?
Vaginal discharge/ itching
Involuntary loss of urine
Bleeding
Hot flashes/ menopause symptoms 		Sexual problems
Cramps
Other


Past Medical History
Hypertension
Diabetes
Heart Problems
Cancer
Hepatitis
Phlebitis or Blood Clots
Transfusions

Asthma
Thyroid Disease
Migraines
Seizures
Gastro-intestinal Problems
Fractures
Anemia
Bladder / Kidney Problems

Surgical History (please list all operations and dates)

Social History
Smoke Drink Marital Status
Exercise No Yes
Type & Frequency

Current Drugs and Medications
(including non-prescription medicines, vitamins, Natural products, etc.)

Allergies (to drugs and medications)

Family History
Mother living?
Yes No Current age/Age at Death
Father living?
Yes No Current age/Age at Death
List any family members with a history of the following disorders:
Heart Attack
Breast Cancer
Stroke
Ovarian Cancer
Diabetes
Uterine Cancer
Hypertension
Colon Cancer
Prostate Cancer
Other Cancers

GYN HISTORY
First day of your last menstrual period:
Age at first menstruation
Length of periods (total bleeding days):
Do you have regular periods? Yes No
Usual Interval: days
Cramps? None Mild Moderate Severe
Flow: Light Medium Heavy Clots
Do you suffer from PMS or mood changes each month? No Yes Help!

Contraception History
Have you ever used? (Check all that apply):
Pill Diaphragm Condom Injections (Depo-Provera)

Have you ever had a problem with any form of contraception? No Yes
If yes, which type and why:


Present method of contraception: If you are using a pill, which one?


Have you ever taken Estrogen (hormone) Replacement? No Yes
If yes, what did you take?


If you are currently taking any hormones (including Natural products), please list them

OBSTETRICAL HISTORY
Total number of pregnancies
Number of living children
Full term pregnancies		 Miscarriages
Abortions
Pregnancy complications

Date of last pelvic exam Date of last Pap Smear
Date of last mammogram Date of last blood work up
Name of other Physicians you currently see or have seen in the past 5 years