New Patient History Form (Age 18 and over)
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- Cecily Bruce
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1 New Patient History Form (Age 18 and over) Obstetrics & Gynecology Name Age Date first middle last Occupation Marital Status: c Single c Married c Divorced c Widowed Referred to our office by: What is the purpose of your visit? If you have a specific problem, please describe briefly: How long have you had this problem? Have you consulted anyone else? Describe any previous testing and/or treatment: Please list all medications you are currently taking. Please include over the counter medications and herbal supplements. Please list all allergies to medications, latex, iodine, foods: GYNECOLOGY REVIEW Last Pap Smear: Last Mammogram: Last Bone Density: Date of last normal period: How often does your period come? Every Age when your periods first started: days How many days do you usually bleed? I use pads and/or tampons on my heaviest days How many? How many? Do you have significant pain with your periods? Do you bleed or spot between periods? Do you bleed or spot after sex? Do you have to take any pain relievers during your period? If yes, what do you usually take? How much? 1 of 5
2 What form of birth control do you use? c Birth control pills Name: c IUD Type: How many years? Date of insertion: c Vasectomy c Rhythm/Natural Family Planning c Tubal Ligation c Hysterectomy c Diaphragm c Condoms/Foam/Suppositories c Menopause c Not sexually active : Have you reached Menopause? Age of onset: Do you have hot flashes? Night sweats? Vaginal dryness/painful intercourse? Trouble sleeping? Have you taken hormone replacement therapy? Medication taken Duration of treatment Reason for discontinuation? Herbal or natural supplements Have you ever had an abnormal pap smear? What year? Describe any treatment/follow-up: Do you have a vaginal discharge? Describe: Have you used medication for the discharge? Medication used: Do you douche? If so, how often? What do you use? Have you been treated in the past for a vaginal infection? c Yeast c Chlamydia c HPV/genital warts c Trichomonas c Gonorrhea c Herpes/HSV virus c Syphilis c Bacterial/BV c Pelvic Inflammatory Disease Do you have pain during or after intercourse on a regular basis? Do you have any concerns with sexual function/desire? Do you have concerns with PMS? Have you ever been exposed to DES that you know of? Do you have a history of physical/sexual/emotional abuse? If yes, did you undergo counseling/treatment? Is this something you would like to talk about? Do you feel safe in your home? 2 of 5
3 Do you have concerns regarding your bladder? Do you leak urine when you cough/laugh/exercise/sneeze/have sex? How many times a day do you leak? If you leak on a regular basis, do you leak small or large amounts? Do you have to wear a pad regularly because of your leakage? How many pads do you use in 1 day? How many times a night do you get up to urinate? If you need to urinate, can you make it to the bathroom or do you leak on the way? Do you feel like you can completely empty your bladder? Do you ever have to apply pressure to your bladder or have to change positions to empty your bladder? Do you ever have to apply pressure to your rectum to have a bowel movement? Have you had a history of Urinary tract infections? How many in the past year? Have you ever seen a Urologist? Have you ever had bladder testing? Have you ever had surgery or treatment for any bladder issue? Explain Do you currently have: Burning with urination Blood in your urine Frequency Urgency Do you perform monthly breast self-exams? Any significant breast changes that you have noticed? Do you have: c breast lumps c nipple discharge c breast tenderness SOCIAL HISTORY Do you consume caffeine daily? Servings/day Do you drink alcohol on a regular basis? Drinks/week Do you smoke? Packs/day Have you smoked cigarettes in the past? When did you quit? Do you use drugs on a regular basis? Type and how much? Have you used IV drugs in the past? Do you think yourself as: (Response to this question is optional) c Straight/Heterosexual c Lesbian/Gay/Homosexual c Bisexual c Something else c Don t know 3 of 5
4 OBSTETRICAL HISTORY Please list pregnancies, miscarriages, and terminations from past to current: Date Length of pregnancy D&C Vaginal/C-Section Girl/Boy Weight Complications SURGERIES AND HOSPITALIZATIONS (Use a separate piece of paper if more space is needed) Surgery/Hospitalization Date Reason/Diagnosis WOULD YOU ACCEPT A BLOOD TRANSFUSION IF NEEDED IN CASE OF EMERGENCY? c YES c NO FAMILY HISTORY Relationship Age Age at Death Medical conditions Mother Father Brother Brother Sister Sister Spouse Does anyone in your family have Breast Cancer? Does anyone in your family have Ovarian Cancer? Does anyone in your family have Colon Cancer? Does anyone in your family have Osteoporosis or Osteopenia? 4 of 5
5 PAST MEDICAL HISTORY Have you ever had any of the following? c Hypertension c Diabetes c Kidney disease/stones c Lung Disease/COPD c Heart Disease/heart attack c Stroke c Epilepsy/Seizures c Asthma c Blood clot/dvt/pulmonary embolus c Hypothyroid/Hyperthyroid c Anemia c Osteoporosis/osteopenia c GERD/hiatal hernia c Lupus/Rheumatoid Arthritis/Sjogren s c Depression/Anxiety c Multiple Sclerosis c Bleeding disorder (Von Willebrands/Hemophilia) c Cancer Type: c Hepatitis c A c B c C c HIV/AIDS PLEASE LIST ANY OTHER PERTINENT MEDICAL INFORMATION Reviewed with patient Date 5 of 5
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