IMMUNIZATIONS: Check off any vaccinations you have had. Add year if known. Check the box if you don t know the information

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Health History for NEW Patients Name: Date of Birth: Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. Please fill in all five pages. If you cannot remember specific dates, please provide your best guess. If you are uncomfortable with any question, do not answer it. Thank you! Main reason for today s visit: Other concerns: What are your health goals for the next year? Where/with whom was your prior gyn care? In the past 2 weeks, have you been bothered by: Little interest or pleasure in doing things? Feeling down, depressed or hopeless? REVIEW OF SYMPTOMS: Please mark the box and/or circle any persistent symptoms you have had in the past few months. Read through every section and check no problems if none of the symptoms apply to you. List other concerns above. General Unexplained weight loss / gain Unexplained fatigue / weakness Fall asleep during day when sitting Fever / Chills Musculoskeletal Neck pain Back pain Muscle / joint pain Neurological Headache Memory Loss Fainting Dizziness Numbness / tingling Unsteady gait Frequent falls Seizures Psychiatric Anxiety / stress / irritability Sleep problem Lack of concentration Endocrine Heat or cold sensitivity Skin New / Change in mole Rash / Itching Cardiovascular Chest pain / discomfort Palpitations (fast or irregular heartbeat) Gastrointestinal Heartburn / reflux / indigestion Blood or change in bowel movement Constipation Incontinence of flatus or stool Respiratory Cough / wheeze Loud snoring / altered breathing during sleep Short of breath with exertion Hematologic/Lymphatic Swollen glands Easy bruising Eyes Change in vision / eye pain / redness Ears/Nose/Throat Nosebleeds, trouble swallowing Frequent sore throat, hoarseness Hearing loss / Ringing in ears Genitourinary Blood in urine Urinary frequency Loss of urine with cough/sneeze Urinary urgency Vaginal discharge Concern with sexual function Pre- menstrual symptoms (bloating, cramps, irritability) Problem with menstrual periods Hot flashes / night sweats Pain with sex Vaginal dryness Vaginal/Vulvar itching/irritation Allergic/Immune Hay fever / allergies Frequent infections Breast Breast lump / pain / nipple discharge IMMUNIZATIONS: Check off any vaccinations you have had. Add year if known. Check the box if you don t know the information Tetanus (Td) With Pertussis (Tdap) Varicella (Chickenpox) shot or illness Pneumovax (pneumonia) Influenza (flu shot) Hepatitis A Hepatitis B MMR Meningitis Zostavax (singles) HPV (Circle number of injections you received: 1 2 3 ) Women s Wellness & Gynecology Page 1 of 1

MEDICATIONS: Please list (or show us your own printed record) all prescription and non- prescription medications, vitamins, home remedies, birth control pill, herbs, inhalers, etc. Use the back of the last page of this form if you need more room and let us know you wrote there. TAKE NO MEDICATIONS Medication Dose (e.g. mg/pill) How many times per day? Allergies / Intolerance Type of Reaction NO KNOWN ALLERGIES HEALTH MAINTENANCE SCREENING TESTS: Lipid (Cholesterol) Date Abnormal? Sigmoidoscopy or Colonoscopy (Circle One) Date Polyp? Eye Exam Date Dental Exam Date Bone Density Test Date Abnormal? Mammogram Date Abnormal? Pap Smear Date Abnormal? PERSONAL MEDICAL HISTORY: Do you have now (current) or have you had (past) any of the following conditions? NONE Condition Code Current Past Comments Abnormal Pap 795.0 When? Alcohol/Drug Abuse 305.00/305.90 Allergy (Hay Fever) 477.9 Anemia 285.9 Anxiety 300.00 Arthritis (Rheumatoid) 714.0 Arthritis (Osteoarthritis) 715.90 Asthma 493.90 Bladder Problems Blood Clot (Leg) 453.40 Blood Clot (Lung) 415.11 Blood Transfusion V58.2 Breast Lump (benign) 611.72 Cancer Breast 174.9 Cancer Colon 153.9 Uterine Cancer 182.0 Cancer Ovarian 183.0 Cancer Other Type Where? Cataracts 366.9 Chicken Pox 052.9 Colon Polyp 211.3 Coronary Artery Disease 414.00 Depression 311 Diabetes (Adult/Childhood Onset) 250.00/250.01 Diverticulosis 562.10 Emphysema 492.8 Fractures (broken bones) Where? Gallbladder Disease 574.20 Gastroesophageal Reflux (GERD) 530.81 Glaucoma 365.9 Women s Wellness & Gynecology Page 2 of 2

PERSONAL MEDICAL HISTORY (CONT.) Code Current Past Comments Gynecological Conditions (Endometriosis) 617.9 Gynecological Conditions (Fibroids) 218.9 Gynecological Conditions (Other) Heart Attack 410.90 Hepatitis (A, B, C, other) Which type? High Blood Pressure 401.9 High Cholesterol 272.0 Hip Fracture 820.8 Irritable Bowel Syndrome 564.1 Kidney Disease / Failure 586 Kidney Stones 592.0 Liver Disease 573.9 Migraine Headaches 346.90 Osteoporosis 733.00 Pneumonia 486 Seizure / Epilepsy 780.39 Sexually Transmitted Infection Which type(s)? Skin Condition (Eczema) 692.9 Skin Condition (Abnormal Moles) 238.2 Sleep Apnea 780.57 Stomach Ulcer 531.90 Stroke 434.91 Thyroid (Nodule) 241.0 Thyroid High (Overactive)/ Hyperthyroidism 242.90 Thyroid Low (Underactive)/ Hypothyroidism 244.9 Other (List) Surgical History: Please check off any procedure or surgeries. List any abnormal finding or complications. NONE Surgical Procedure Check if Yes Year Comments Abdominal Surgery (Major) Appendectomy (appendix removal) Back Surgery (Lumbar) Biopsy (location) Breast Biopsy Circle: Right Left Both Breast Surgery Circle: Right Left Both Coronary Bypass Coronary Stent Dilation & Curettage (D&C) EGD (Stomach Endoscopy) Endometrial Ablation Cataract Gallbladder Removal Circle: Laparoscopic Heart Surgery (other than Coronary Bypass) Hernia Removal Circle: Abdominal Inguinal Hip Surgery Hysterectomy (total, including ovaries) Circle: Laparoscopic Vaginal Abdominal Hysterectomy (partial, ovaries left) Circle: Laparoscopic Vaginal Abdominal Knee Surgery Circle: Right Left Both LEEP (Cervix Surgery) Neck Surgery Ovary Removal Circle: Right Left Both Sigmoidoscopy / Colonoscopy Tonsillectomy/Adenoidectomy Tubal Ligation Other (List) Women s Wellness & Gynecology Page 3 of 3

OB- GYN HISTORY Age of first period: Periods come every days Period last days Approximate date of last menstrual period: If not menstruating, age when periods stopped: Total number of pregnancies: Number of vaginal births: Number of C- sections: Number of miscarriages: Number of Abortions: Number of Ectopics: Adopted - Yes No (Please Circle) If yes and you do NOT know your family history skip this section and continue to page 5 (Social History). FAMILY HISTORY - Indicate which relative has had the following diseases (parents and siblings are most important). Disease D - Deceased A - Alive No significant history known Alcoholism/Drug Abuse Alzheimer s / Dementia Asthma Autoimmune Disease Bleeding or Clotting Disorder Cancer Breast Cancer Colon Cancer Ovarian Cancer Uterine Cancer Other Type Colon Polyp Coronary Artery Disease (e.g. heart attack, angina) Depression/Suicide/Anxiety Diabetes (adult onset) Genetic Disorder (explain) Glaucoma Heart Disease (Other) High Blood Pressure Hypertension High Cholesterol Hip Fracture Hypothyroidism/Thyroid Disease Kidney Disease Kidney Stones Macular Degeneration Migraine Headaches Osteoporosis Stroke Thyroid Disease Other (list) Mother Father Sister(s) Brother(s) Mom s Mom Mom s Dad Dad s Mom Dad s Dad Other Relative Comments Women s Wellness & Gynecology Page 4 of 4

SOCIAL HISTORY: Tobacco Use Smoke Cigarettes: Never (If you ve never smoked please go to Alcohol Use question now) How many years did you smoke? Quit date: Approximately how many packs a day did you smoke? Current Smoker: Packs/day: # of years: Other tobacco: Pipe Cigar Snuff Chew Alcohol Use Do you drink alcohol? # of drinks/week: Beer Wine Liquor Drug Use Do you use marijuana or other recreational drugs? Have you ever used needles to inject drugs? If yes, please circle either - - recreational or prescription Sexual Activity Age you first had sex (if applicable): Number of lifetime sexual partners: Sexual partner(s) is/are/have been: None Male Female Both Sleep Average number of hours of sleep each night: Exercise: Do you exercise regularly? What kind of exercise? How long (minutes)? How often? Diet: How would you rate your diet? Good Fair Poor Would you like advice on your diet? Safety: Do you use a bike helmet? No Bike Do you use seatbelts consistently? Does your home have a working smoke detector? If you have guns in your home, are they locked up? Not applicable Is violence at home a concern for you? Have you ever been forced to have sex? Any history of sexual abuse? Sexually involved currently?: Any history of anal sex? Birth control method (circle below all that apply): No method, Condoms, Pill, Patch, Vaginal Ring, IUD, Tubal Ligation, Diaphragm, Partner has vasectomy, Withdrawal, Natural Family Planning, Depo Shot, Nexplanon,Trying to conceive, None, Abstinence, Hysterectomy/Menopause, Other Would you like to discuss birth control today? Do you wish to be tested for any sexually transmitted diseases today? Occupation (or prior occupation): retired / unemployed / leave of absence / disabled (circle one) Employer: Years of education or highest degree: Marital Status (circle one): Single / Partner / Married / Divorced / Widowed Spouse / Partner s name: Number of children: Ages if under 18 years: Number of grandchildren: Number of great grandchildren: Who lives at home with you? Leisure activities, group involvement, religion, volunteer work, recent travel: Thank you for taking the time to fill this out. Women s Wellness & Gynecology Page 5 of 5

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