New_ Patient _Medical_ History

The Healthy Woman

New Patient History
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Date: ____/____/_____

Name
Age
Email:

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)

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Social History

Smoke Drink Marital Status
Exercise No Yes
Type & Frequency:

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

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Allergies (to drugs and medications)

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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.

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

Last pelvic exam	Last Pap Smear
Last mammogram	Last blood work up
Name of other Physicians you currently see or have seen in the past 5 years.
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Note: the information entered on this form will not be transmitted in any manner and is soley for use on your computer. If you would like to use a non-interactive page please Click Here.