logo color FormHeader FamilyHx

Name of PatientDate of BirthMarital Status  
OccupationEducation
History of Tobacco Use – Current AmountYears of Use
Alcohol Use – Current AmountDrug Use – Current Type & Amount
OBSTETRICAL HISTORY
No. of PregnanciesPremature Births <37 wksMiscarriagesAbortionsEctopicLiving Children
BORN (mo/yr) WEEKS PREG. WEIGHT lbs/oz SEX DLV. TYPE REMARKS
/ / MF VagC-Sec
/ / MF VagC-Sec
/ / MF VagC-Sec
/ / MF VagC-Sec
/ / MF VagC-Sec
/ / MF VagC-Sec
GYNECOLOGICAL HISTORY
Menstrual History – Age at First PeriodAge at Menopause
Regular periodsYesNo   Comments
Vaginal Infection / Sexually Transmitted Infection History: Please check if you have ever had any of the following:
Chronic Yeast Infections TrichomonasChronic Bacterial VaginosisChlamydiaHerpesGonorrheaSyphilisPelvic Inflammatory DiseaseHuman Papilloma Virus (HPV, Warts)Other
(If you find any of the Sexual History questions particularly offensive, leave blank and discuss with your Provider)
Sexual History: Have you ever had sex? Yes No   Age at first sexual experienceNumber of lifetime partners
Are you currently sexually active? Yes No   Do you have sex with males females both
Contraceptive History: Current method Other methods you have used
Pap Smear History: Date of last Pap SmearAny history of abnormal Pap?YesNo
Please list any treatments you have had for abnormal Paps

PAST MEDICAL HISTORY
Please check if you have had any of the following conditions
1. Migraines 18. Thyroid Disorder
    w/Aura (Neurologic Changes)     Hypothyroidism
2. Heart Disease/Problems     Hyperthyroidism
    Type 19. Diabetes
3. High Blood Pressure     Gestational Diabetes
4. High Choleseterol 20. Cancer -
5. Respiratory (Lung) Disease/Problems   Cancer -
    Type 21. Epilepsy/Seizures/
6. Asthma 22.   Neurological Disorders/Problems
7. Breast Disease/Problems     Type
  Type 23. Arthritis
8. GERD/Reflux 24. Osteoporosis
9. Stomach Ulcers 25. Autoimmune Disease/Problems
10. Bowel Disease/Problems     Type
  Type 26. Endometriosis
11. Kidney Disease/Problems 27. Fibroids of Uterus
  Type 28. Infertility
12. Urinary Incontinence 29. Uterine/Cervical Abnormality
13. Recurrent/Frequent Urinary Infections     Type
14. Blood Disorders 30. Anxiety
  Type 31. Depression
15. Blood Transfusions 32. Abuse/Domestic Violence
16. Blood Clots - DVT, PE 33. Other -
17. Skin Disease/Problems   Other -
  Type      
SURGICAL HISTORY
Hospital Admissions/Surgeries (date/reason)

FAMILY HISTORY
Please state if each family member is living or deceased, current age or age at death, any major medical problems or cause of death.
FAMILY MEMBER LIVING-AGE DECEASED-AGE-CAUSE OF DEATH MEDICAL PROBLEMS
Mother
-
--
Father
-
--
Mother’s Mother
-
--
Mother’s Father
-
--
Father’s Mother
-
--
Father’s Father
-
--
Siblings
-
--
Siblings
-
--
Siblings
-
--
Siblings
-
--
Children
-
--
Children
-
--
Children
-
--
Children
-
--
Children
-
--
Please list known close blood relatives with any of the following problems.
CONDITION RELATIVE RELATIVE RELATIVE RELATIVE
Breast Cancer
Ovarian Cancer
Endometrial/Uterine Cancer
Colon Cancer
High Blood Pressure
High Cholesterol
Heart Disease/Heart Attack
Osteoporosis
Blood Disorders/Bleeding Problems
Diabetes
Twins or Triplets
Congenital, Genetic or Birth Defects
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Date