Women’s Health Center PERSONAL AND FAMILY MEDICAL HISTORY Date: __________________________ Allergies: _____________________________________________________________________________________________
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Medications — Please list all of the medications you are taking, including any vitamins, herbal medicines and “over-the-counter” medications. Name of Medication Frequency Medical History — Please check (;) if you have had any of the following conditions. None
D.V.T. or P.E. (blood clots) G.E.R.D. (reflux)
Bleeding or clotting disorder Liver disease or hepatitis
Other: ____________________________________________________________________________________________
Obstetric and Gynecologic History
Total # of pregnancies: _____________ # of vaginal deliveries: ______________ # of C-sections: ___________________
# of children: _____________________ # of miscarriages: _________________ # of abortions: ____________________
Are you in menopause? Yes No If “no,” please complete the following:
Date of last menstrual period: ______________ # of days between cycles (first day of one to the first day of the next): _____
Date of last Pap Smear: _____________ Have you had any abnormal Pap Smears? Yes No If “yes,” when? _______________
Are you currently sexually active? Yes No Total number of partners in your lifetime: 0 1-5 6-10 >10
My partner(s) is(are): Male Female Both
Have you ever had a sexually transmitted infection or pelvic inflammatory disease? Yes No
If “yes,” which one(s): _________________________________________________________________________________
List any gynecologic procedures or surgeries that you have had: _________________________________________________
____________________________________________________________________________________________________
Method of Birth Control
Other: ____________________________________________________________________
Immunizations — Please provide your most recent immunization dates for .
Tetanus/diphtheria: ________________________________ Hepatitis B: _________________________________________
Tetanus/dipththeria/pertussis _________________________ Varicella: ___________________________________________
Have you ever had chicken pox? Yes No
Please check (;) if you currently have any of the following:Surgical History Please list all the surgeries you have had, including the dates: ___________________________________________________
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_____________________________________________________________________________________________________
Social History Occupation: ___________________________________________________________________________________________
Are you? Married Single Divorced Widowed Separated Significant other Other: ________________
Highest level of education: College High School G.E.D. Other:___________________________________________________________
Do you smoke? Yes No If “yes,” how many cigarettes per day and for how long? _______________________________
Do you drink? Yes No If “yes,” the number of drinks per day:______________________________________________
Have you ever used any recreational drug? Yes No If “yes,” which one(s) and when? ______________________________________
Do you get regular exercise Yes No If “yes,” how often? _________________________________________________
Do you have any dietary restrictions? Yes No If “yes,” what restrictions?_____________________________________
Do you want to discuss abuse? Yes No
Family Medical History Maternal Paternal Condition Father Grandfather/ Grandfather/ Grandmother Grandmother
O N B E K E N D E R I S I C O ’S V O R M E N R is ic o m a n a g e m e n t is e e n v a n d e e s s e n tië le e le m e n te n v a n c o r p o r a te g o v e r n a n c e b in n e n d eE E N B E D R E I G I N G ; B E K E N D E R I S I C O ’S o n d e r n e m in g . H e t n e m e n v a n r is ic o ’s is in h e r e n t a a n h e t o n d e r n e m e r s c h a p . D o o r h e t n e m e nZ I J
Women’s Health Center