Women’s Health Center
Date: __________________________
Allergies: _____________________________________________________________________________________________
______________________________________________________________________________________________________ MedicationsPlease list all of the medications you are taking, including any vitamins, herbal medicines and “over-the-counter” medications.
Name of Medication
Medical HistoryPlease 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: ____________________________________________________________________ ImmunizationsPlease 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: ___________________________________________________
_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 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
Condition Father
Grandfather/ Grandfather/
Grandmother Grandmother



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