Your Past Medical History
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- Geraldine Green
- 6 years ago
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1 Name: Date of Birth: Date: Referred By: Reason for Today s Visit: Routine Annual/Wellness Exam OR Gyn Problem, Post Op, etc (please describe) Your Past Medical History ( PLEASE CIRCLE the history that applies to YOU) CANCER: BRCA Tested Breast Cervical Colon Endometrial Lung Ovary Skin Vaginal Vulvar CARDIAC: Heart Arrhythmia Heart Disease High Blood Pressure High Cholesterol DERMATOLOGY: Acne Eczema/Psoriasis E NT: Hearing Loss Endocrinology: Diabetes History of Gestational Diabetes Elevated Prolactin Osteopenia Osteoporosis Thyroid Problems EYES: Cataracts Glaucoma GI: Colon Polyps Crohn s/ Ulcerative Colitis Reflux/Stomach Ulcers Gallbladder Disease Vitamin Deficiency Hemorrhoids Irritable Bowel Syndrome Liver Disease Hepatitis HEMATOLOGY: Anemia Bleeding Disorder Blood Clotting Disorder/Factor V Leiden Blood T ransfusion DVT/Pulmonary Embolism INF EC T IOUS DIS EA S E:
2 Chicken Pox/Shingles HIV MRS A Rheumatic Fever Tuberculosis/Positive PPD NEUROLOGY: Headaches/Migraines Mem ory Loss/Dementia Neuropathy Seizures/Epilepsy Stroke/TIA ORTHO: Chronic Back Pain Degenerative Joint Disease Fractures PSYCH: ADD PMS/PMDD Anxiety Disorder Bipolar Disease Depression Eating Disorder PULMONARY: Asthma COPD/Emphysema Seasonal Allergies/Allergic Rhinitis Sleep Apnea RHEUMATOLOGY: Arthritis Autoimmune Disease Fibromyalgia/Chronic Pain Restless Leg Syndrome UROL OGY: Frequent Urinary T ract Infec tions Hematuria (blood in urine) Urinary Inc ontinenc e Inters titial Cystitis Kidney Disease Kidney Infec tion Kidney Stones WEIGHT MANAGEMENT: Obesity SURGICAL HISTORY List any operations/hospitalizations/serious illness you have had (including GYN surgeries) and the date of each: ME D IC A T IO N S : List all medications you are currently taking (including herbal and over the counter):
3 Medic at ion Dosage Physician Allergies Medic at ion Reaction Onset Date or No Known Allergies
4 Your GYN History Date of Last Period Age of first period Your age at the birth of your first c hild: Have you gone through Menopause? Yes or No At what age Years of PostMenopausal HRT use: How often do you start your period? Frequency of cycle? Duration of flow: Is flow (circle one): lig ht, medium, heavy, irregular Cramps Current form of Birth Control? Sexual orientation: Sexually active? Yes or No Total lifetime partners? History of STD- PID? History of Abnormal Pap? Yes or No Date of most recent Pap smear History of breast problems? Yes or No History of abnormal mammogram? Yes or No Date of Last Mam m og ram History of Endometriosis? Yes or No Date of Endometrial Biopsy: History of Fibroids: Yes or No History of Infertility? Yes or No History of Ovarian Problems? Yes or No History of PCOS? Yes or No Date of last: Ultrasound: Vulvar Biopsy: Colonoscopy Dexa Scan Your Family History ( Please write in the relationship to the family member with a history of these illnesses; only indicate blood relatives (mother, father, brother, sister, son, daughter, grandmother, grandfather, aunt, uncle) Problem Relation Problem Relation Blood clotting Cancer Uterine disorder Cancer - Breast Dementia Cancer Diabetes Mellitus Cancer - Cervical Heart Disease Cancer - Colon High Blood Pressure Cancer - Endometrial High Cholesterol Cancer - Lung Osteoporosis C ancer - Melanom a Hereditary Disease Cancer - Pertinent History Cancer - Ovarian Stroke Cancer - Pancreatic Thyroid Disease Your Social History Have you ever smoked? Yes or No Do you Smoke? Yes or No # of packs per day # of years smoking Do you drink alcohol? Yes or No # of D rinks per week Drug User? Yes or No Type of Drug How Often
5 Caffeine Intake? Do you exercise? Yes or No How Often? Do you have a Special Diet? Ma rit a l S t a t u s Do you have a history of Physical abuse? Sexual Abuse? Emotional Abuse? Level of Education: Occupation: Seat belts used routinely?: Yes or No Is blood trans fus ion ac c eptable in an emerg enc y? Yes or No Vaccines( indicate date received) : Hepatitis B MMR Gardisil _ Preferred Pharmacy Name and Number Your Primary Care Provider Name and Number Your OB History Total # of pregnancies # of Abortions # of miscarriages Past Pregnancies (Last Six) Date Month/ Day / Y ear GA Weeks Length of Labor Birth Weight Sex M/ F Type Delivery Anesthesia Place of Delivery Preterm Labor Y/N Comments
6 Review of Symptoms Please check (x) if any of the following applies to you now. Symptom X Notes Symptom X Notes Constitution Genitourinary Fatigue Fever Weight Gain Weight Loss Skin Moles Rash Breast changes Eyes Irritation Vision Changes ENMT Hearing Loss Ear Pain Sinus Problems Sore Throat Snoring Dry Mouth Mout h Ulc ers Respiratory Shortness of Breath Cough Sputum Wheezing Cardiovascular Chest pain Palpitations Problems breathing Gastrointestinal Trouble swallowing Blood in Urine Abnormal Bleeding Pain in sides/trunk Trouble Urinating Inc ontinenc e Painful Urination Frequency of Urination Urgency of Urination Rash Lesion Discharge Inc ontinenc e Vaginal Odor Vaginal Itching Endocrine Menst rual Problem s PMDD Symptoms Breast pain/tenderness Bloating Menopaus al Symptoms Decreased Sex Drive PMS Painful Intercourse Musculoskeletal Mus c le ac hes Mus c le weaknes s Joint pain Back pain Neurological Headaches Dizziness Loss of Consciousness Numbness
7 Nausea Vomiting Abdominal Pain Bowel Changes Diarrhea Constipation Rectal Bleeding Seizures Psychiatric Depression Alcoholism Sleep disturbances OTHER:
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