NAME: _______________________________________________________ AGE:_____________ DATE: ____/____/____ BIRTHDATE:____/____/____ REFERRED BY: ________________________________________________________________________ MARITAL STATUS: M_______S_______D_______W_______ REASON FOR VISIT: o ROUTINE PHYSICAL o PREGNANCY PROBLEM: __________________________________ _______________________________________________________________________________________________________________ PRIMARY CARE PHYSICIAN ____________________________________ PLACE of EMPLOYMENT_________________________ CHECK IF YOU HAVE EXPERIENCED ANY OF THESE MEDICAL PROBLEMS PRESENTLY OR IN THE PAST: MAJOR ILLNESSES YES NO YES NO Anemia (Chronic) Hepatitis / Jaundice Past____ Present____ Anxiety High Blood Pressure Arthritis (Rheumatoid) High Cholesterol Asthma Kidney Stones Bipolar Disorder Osteoporosis____ Osteopenia____ Blood Transfusions or Blood Clotting Disorder Reflux (Gastric) Breast Cancer Rheumatic Fever Cancer (Specify Type) _____________ Sexually Transmitted Diseases (Specify Type) Herpes: Type 1____ Type 2____ Chlamydia___ Gonorrhea____ HIV/AIDS___ HPV High___ Condyloma/Genital Warts____ Chronic Obstructive Pulmonary Disease Stroke Depression Tuberculosis - TB Diabetes Type 1____ Type 2____ Thyroid Disease Controlled? Yes____ No____ Hyperthyroidism____ Hypothyroidism____ Fracture (s) Urinary Tract Infections Glaucoma OTHER: Heart Murmur Heart Attack WHEN WAS YOUR LAST TEST OR IMMUNIZATION? DATE DATE Abnormal PAP Smear Flu Shot Bone Density Pneumonia Immunization Colonoscopy Tetanus Mammogram TB Skin Test Last Pap Smear Performed HPV Series Dates 1st_____2nd_____3rd_____ PLEASE LIST ANY PAST INJURIES OR ILLNESSES: DATE DATE TYPE TYPE DATE SURGERY REASON PAGE 1 NAME: ______________________________________________________________ DRUG NAME BIRTHDATE: ____/____/____ PLEASE LIST MEDICATIONS THAT YOU ARE CURRENTLY TAKING: DOSAGE PHYSICIAN DRUG NAME DOSAGE *** Allergic to Latex*** YES NO Please Choose One PHYSICIAN *** Drug Allergies / Reactions*** 1. ____________________ 2. ________________ 3. ________________ 4. ____________________ 5. ________________ 6. ________________ Food Allergies: ________________________________________________ FAMILY HISTORY: Please choose one (P) Father’s or (M) Mother’s side also specify grandparents, brothers, sisters, aunts or uncles YES Check NO Acid Reflux Anemia (chronic) Arthritis/Joint pain Asthma Breast Cancer Cancer (specify type) Chronic Lung Disease (COPD) Depression / Anxiety / Bi-Polar Diabetes Glaucoma Heart Trouble / Murmur Hepatitis / Jaundice High Blood Pressure High Cholesterol Kidney Infections / Stones Stroke Thyroid Disease Tuberculosis - TB OTHER: P P P P P P P P P P P P P P P P P P P YOUR GYN HISTORY Do you use birth control? o Yes o No q Condoms q Nuvaring q Depo Provera q Birth Control Patch q Diaphragm q None q IUD- What Kind ? q Natural Family Plan/Rhythm - Date Inserted: q Tubal Ligation/Occlusion/Essure q Birth Control Pill q Vasectomy – Name: q Withdrawal q Contraceptive Foam/Jelly q Other: What age did you have your first period: _____________ How many days are there from start of period to start of next period: ________ days How long does your period last? _______ days Flow: o Light o Medium Number of Tampons per day: ____________ Number of Pads per day: ____________ Date of Last Period: ________________ Do you have clots? o Yes o No Do you have breakthrough bleeding? Do you have cramps? o Yes o No Do you have pain? Have you ever had an abnormal mammogram? [] Yes [] No Date: ____/____/____ Have you gone through Menopause? o Yes o No At what age? ____________ Are you on Hormone Replacement Therapy (hormones)? o Yes o No PAGE 2 M M M M M M M M M M M M M M M M M M M o Heavy o Yes o Yes o No o No NAME: ____________________________________________________________ BIRTHDATE: _____/_____/_______ YOUR OB HISTORY NUMBER Full term births Abortions Induced Living children Total # of pregnancies Premature Miscarriages NUMBER On the chart below, please fill in answers for each pregnancy including abortions or miscarriages. If you have had a tubal ligation, previous hysterectomy, or if you are postmenopausal you may skip to the next section. Under the “Baby’s Weight/Sex” column, please input “M” for Male and “F” for female. No. Birth Date Wks Gest Labor (hrs) Baby’s Del Type Weight/Gender Vag/CSection Anes Early Labor? Wt Gain Comments / Complications Location 1 2 3 4 5 SOCIAL HISTORY PLEASE LIST HABITS Do you use Seat Belt? o Yes o No Do you do perform a Self Breast Exam? o Yes o No Do you drink milk? o Yes o No How many glasses per day? Do you Eat cheese or other dairy products? o Yes o No Servings per day: Do you take calcium? o Yes o No Name and dosage: Do you exercise? o None o Less than 3 times per week o More than 3 times per week Are you Sexually Active? o Yes o No Do you have sex with? o Men o Women o Both First Intercourse at Age: ______________ Frequency: __________ / Week New sexual partner o Yes o No How Long? ________ Lifetime sexual partners o Less than 5 o More than 5 Do you smoke? o Yes o No Packs per day: _______________ Number of Years: _______________________ Do you consume alcohol? o Yes o No Drinks per day: _______________ Drink per week: _________________________ Do you use recreational drugs? o Yes o No What kind? Frequency: History of abuse? o Yes o No o Physical o Emotional o Sexual List all “Natural” or Herbal remedies, over the counter drugs, vitamins or PREFERRED PHARMACY minerals you are taking on a regular basis. *Name ________________________ *Its Location _____________________ *Phone Number ___________________ PAGE 3 NAME: _______________________________________________________ BIRTH DATE: ____/____/_____ REVIEW OF SYSTEMS: PLEASE CHECK (X) IF ANY OF THE FOLLOWING APPLIES TO YOU NOW. CONSTITUTIONAL NOTES GENITOURNARY (CONT) Weight Loss q Decreased sex drive q Weight Gain q Painful intercourse q Fever q Possible Pregnancy q Fatigue q Genital Sores q Night Sweats q Hot Flashes q SKIN EYES Rashes q Double vision q Itching q Vision changes q Skin Dryness q HENT Skin Lesions q Headaches q Changes to Lesions or Moles q Dizziness q Acne q Sore Throat q Sinus Pain q NEUROLOGICAL Nose Bleeding q Muscular Weakness q Thyroid Mass q Numbness or Tingling q Neck Pain q Difficulty Concentrating q BREAST Memory Difficulties q Lumps q Speech Difficulties q Tenderness q Seizures q Swelling q Loss of Balance q Discharge q Pain in Breast q MUSCULOSKELETAL Abn Changes in Breast q Joint Pain or Swelling q Muscle Pain q CARDIOVASCULAR Back Pain q Chest Pain q Irregular Heart Beats q ENDOCRINE Rapid Heart Rate q Loss of Hair q Fainting q Difficulty Tolerating Cold q Swelling of legs q Difficulty Tolerating Heat q Varicose veins q PSYCHIATRIC RESPIRATORY Anxiety q Wheezing q Depression q Cough q Impulsive Behavior q Shortness of breath q Suicidal Thoughts q Spitting up blood q Excessive Anger q GASTROINTESTINAL Mood Swings q Nausea q Emotional Abuse q Vomiting q Physical Abuse q Diarrhea q Sexual Abuse q Constipation q HEMATOLOGIC/ Abdominal Pain q LYMPHATIC Bloody / Black Stool q Bruises, frequent or easily q Hemorrhoids q Cuts do not stop bleeding q Jaundice q Enlarged lymph nodes q GENITOURNARY Urgency of urination Frequency of urination Pain with urination Nighttime urination Losing urine Blood in urine q q q q q q ALLERGIC/IMMUNOLOGIC Frequent illness Seasonal Allergies OTHER 1. 2. 3. PAGE 4 q q NOTES