BLUE RIDGE WOMEN’S HEALTH CENTER PATIENT MEDICAL HISTORY

Name______Date of Birth______Date______

Do you have any food or drug allergies? û Yes û No List:______

Do you have allergies to Latex or Betadine? ú Yes ú No List:______

Do you take any medications at the present time? û Yes û No List name & dosage:______

______Preferred Pharmacy______

Have you ever had? (Please check box)

ú Asthma/Lung Disease ú Hay Fever ú Non-Migraine Headaches ú Epilepsy

ú Thyroid Disease ú Heart Disease ú Kidney Problems

ú Diabetes ú Hepatitis or Liver Disease ú Pelvic/Vaginal Infections

ú Ear/Nose/Throat Problem ú Blood Clots ú Cancer (Type)______

ú High Blood Pressure ú Eye Problems ú Psychiatric Problems

ú Blood Transfusions ú Osteoporosis/Osteopenia ú Bladder Infections or Incontinence

ú High Cholesterol ú Migraine Headaches ú Stomach or Intestinal Problems

Have you ever had surgery on/for any of the following? (Please check box & give reason)

ú Appendix______ú Ovaries______ú Tonsils______

ú Breasts______ú Laparoscopy______ú Tubal Ligation______

ú Hernia______ú Orthopedic______ú Varicose Veins______

ú Gall Bladder______ú Stomach/Bowels______ú Colonoscopy______

ú Hysterectomy______ú Thyroid______ú Bladder or Rectal Repair______

ú D&C______ú Cervix______ú Other______

Have you ever had or have you been exposed to the following? (Please check box)

ú AIDS ú Syphilis ú HPV/Genital Warts ú HIV

ú Herpes ú Gonorrhea ú Chlamydia

Have you, your family, your spouses’ family ever had? (Please check box)

ú Tay Sachs Disease

ú Chromosomal Disorders (such as Down’s, Trisomy 18)

ú Genetic Defects such as spina bifida, anencephaly, meningocele

ú Blood Disorders such as hemophilia, sickle cell disease, thalassemia

ú Cystic Fibrosis

Do you do any of the following? (Please check box)

ú Smoke Cigarettes Amount per day______Number of Years______

ú Drink Alcohol Amount per day______

ú Use street drugs such as cocaine, marijuana, amphetamines Please list:______

Sexual History:

ú Currently sexually active ú Are you using birth control? Type:______

ú Have pain or bleeding with intercourse ú History of rape or sexual abuse

Menstrual History:

Date of first day of last period______At what age did you have your first period?______

Periods are: ú Regular ú Irregular ú Heavy ú Painful

My periods come every ______days and last______days. Any bleeding between periods? ú Yes ú No

Was your last period normal? ú Yes ú No If no, please give first day of last normal period.______

Do you think you might be pregnant now? ú Yes ú No

Last pap smear______Last mammogram______Last Dexascan______

If menopausal, when was last period?______

Do you take hormone replacement? ú Yes ú No Type, Dosage, How Long:______

Have you ever had an abnormal pap smear? ú Yes ú No Date:______

Treatment given for abnormal pap smear?______

Pregnancy History:

Date
Mo/Yr / Weeks
At
Delivery / Length
Of
Labor / Birth
Weight / Sex
M/F / Type
Of
Delivery / Anes. / Place
Of
Delivery / Preterm
Labor
Yes/No / Comments/Complications
List ALL Abortions, Miscarriages & Ectopic Pregnancies
Is this child living?

Have you been treated for infertility? ú Yes ú No

Family History:

FAMILY MEMBER AGE CURRENT HEALTH AGE AT DEATH CAUSE OF DEATH

Father

------

Mother

------

Brother/Sister 1

2

3

4

------

Husband

------

BLOOD RELATIVES WITH RELATIONSHIP AGE AT ONSET

Breast Cancer

------

Ovarian Cancer

------

Uterine Cancer

------

Colon Cancer

------

Diabetes

------

Heart Disease

------

High Blood Pressure

------

Epilepsy/Seizures

------

Stroke

------

Osteoporosis

PRINT & COMPLETE THIS FORM. RETURN TO BLUE RIDGE WOMEN’S HEALTH CENTER PRIOR TO APPOINTMENT BY PERSONAL DELIVERY TO OFFICE, E-MAIL (not secure), FAX, OR U.S. MAIL:

E-MAIL: FAX: 540-433-6605

MAIL: BLUE RIDGE WOMEN’S HEALTH CENTER, PLC

1885 PORT REPUBLIC ROAD HARRISONBURG, VA 22801