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PATIENT HISTORY FORM: Name: Birth Date: Address: Phone: Married SingleDivorced Widowed Separated Allergic to what medicines: Medicines you are now taking: MENSTRUAL HISTORY (Please describe your periods while not taking birth control pills?) Age your period started: Regular? Cramps? Number of days apart: Number of days of flow: Date of last period: Menopause: When? List any problems or remarks about your period: Are you presently using any form of contraception? (birth control) If so, what type? Hysterectomy? When? OBSTETRIC HISTORY Number of pregnancies you have had (include miscarriages): Number of children born alive: Number of miscarriages or abortions: List any complications or remarks:
List any surgery you have had & when (include tonsils, D&C, Tubal ligation and C-section): __________________________________________________________________________________________________ PERSONAL Medical Illnesses, Please Check: Thyroid DiseaseHistory of Blood Clots Liver DiseaseDiabetes Heart DiseaseKidney Disease High Blood Pressure AsthmaTuberculosisEmphysemaEpilepsy or SeizuresCancer Hepatitis Other FAMILY HISTORY Please Check & state who in your family: Diabetes Heart Disease Kidney DiseaseTuberculosis Cancer (type) High Blood Pressure Asthma EmphysemaEpilepsy or Seizures What are you seeing the doctor about today?
Please check: SmokerNon-smokerPacks per day |
