Contraceptive History

Contraceptive History

Circle all the birth control methods that you have ever used. / Please describe any problems you had with any method.
C-Cap/diaphragm/sponge
Condom, male or female
Cream/film/foam/suppository
Depo
IUD
Natural family planning
Norplant
Implanon
Pills
Tubal ligation
Vasectomy
Other:______

Pregnancy History No Yes

Do you plan to have children / more children?
Have you ever been pregnant? (If no, skip to next section)
Did you have diabetes during your pregnancy?
Any children with genetic abnormalities/birth defects?
Are you currently pregnant?
Please list the ages of your living children. / Number of: Pregnancies
Live births
Vaginal deliveries
C-section deliveries
Fetal Deaths
Stillbirths
Miscarriages
Abortions

Family History No Yes

Are you adopted? (If yes, skip this section as appropriate)
Did your mother ever take DES or hormones when she was pregnant with you?
Has your biological Breast cancer
mother, father, Cervical / ovarian cancer
sisterorbrother Diabetes
ever had: Early heart attack or stroke (< age 55 for males)
(< age 65 for females)
High cholesterol

Personal History No Yes

Do you smoke? (If yes: _____ years, ____ cigarettes/day)
Do you drink alcoholic beverages? (If yes: ___ drinks/day)
Do you use drugs? What kind?______Injectable?______
Are you being physically, mentally or sexually abused by a member of your household or a relative?
Do you feel safe at home?
Are you being abused by someone other than a member of your household or a relative?

Allergies No Yes

Do you have any drug allergies?
ALLERGIES:
[ ] aspirin[ ] erythromycin[ ] sulfa
[ ] antispetic[ ] iodine[ ] tylenol
[ ] cipro[ ] latex[ ] other
[ ] copper [ ] lindane
[ ] doxyclycline [ ] penicillin
Do you have a history of any adverse drug reactions?
DRUG REACTIONS: (Please give details)

Medical Treatment No Yes

Have you received medical care elsewhere in the past 6 months?
Are you being treated for any condition currently?
If yes, please explain:
Have you taken any over the counter or prescribed medications in the past 2 months?
The information I have given on this form is correct to the best of my knowledge.

Signatures Date

Patient:
Staff / Title:

MEDICAL & SOCIAL HISTORY

FEMALE PATIENT

Medical/Surgical History

Have you ever had any of the following conditions? / No / Yes / Specify
Anemia
Cancer
Depression/Anxiety/Suicidal Thoughts/Bipolar
Diabetes
Eye problems
Genetic condition/birth defects
Heart disease
High blood pressure
High cholesterol
Liver or gallbladder disease
Neurologic conditions
(stroke, migraine headaches)
Measles/mumps/rubella/mono
Seizure disorder
Sensory difficulties (numbness)
Thrombophlebitis (blood clots)
Ulcers/spastic colon
Urinary tract conditions
(kidney, bladder, urethra)
Have you ever had surgery, hospitalizations,
blood transfusions? / Give Specifics

GYN History

Breast disease
Breast cancer
Cervical/ovarian/uterine cancer
Pelvic infection
Sexually transmitted infection (AIDS, chlamydia, condyloma, genital warts, gonorrhea, herpes, syphilis, trichomonas, Hep. B)
Uterine abnormality

PAP History

Abnormal PAP
Treatment: (please circle) cautery, colposcopy, cone biopsy, cryosurgery, Laser, LEEP, no treatment / Date:

Menstrual/Sexual History

How old were you when you started your period?
How often are your periods? (in days)
How many days does your period last?
On average, how many tampons/pads do you use each day during your period?
No Yes
Do you spot between periods?
Do you have severe cramping during your periods?
Have you ever had sex? Age at 1st intercourse:_____
Are you sexually active now? (If yes, check all that apply)
Vaginal intercourse[ ], Anal intercourse[ ], Oral sex[ ],
Outercourse (stimulation without penetration)[ ]
Have you had sex with a [ ] Man [ ] Woman [ ] Both
Has your partner had any of the following? (Check all that apply)
Multiple partners[ ], Hx of STD [ ], HIV [ ],
Used injectable drugs [ ]
Has your partner had sex with a
[ ] Man [ ] Woman [ ] Both
Number of sex partners in your life? MEN ____ WOMEN ____
Do you currently have more that one partner?
Have you changed partners recently (last 6 months)?
Do you and your partner only have sex with each other?
Are you having sex because you want to?
Are you having sex because someone is forcing you?
Do you have bleeding during or after sex?
Is sex painful for you?

Form 226 Rev: 02/28/2009