Current History Review

Current History Review

Name / Home Phone / Date
Street Address / Work Phone / Birthday
City, State, Zip / Insurance / Marital Status
Occupation / Spouse/Partner’s
Name / Education
What brings you to the office today?
ڤAnnual Exam/Routine Care
ڤProblem/Issue (Please describe briefly)
ڤI was referred by
Past Hospitalizations and Surgery:
Current Medications: / Allergies to Medications:
Bad Habits / Gynecologic History

Yes No

/

Describe

/ Last Menstrual Period: /

Every Days.

LastingDays.

ڤ ڤ

/

Smoking

/ Last Pap Smear: / Normal?

ڤ ڤ

/

Alcohol

/ Last Mammogram: / Normal?

ڤ ڤ

/

Illegal Drugs

/ Current Method of Contraception:
Have you or anyone in your family suffered from: (Indicate relationship)
ڤDiabetes / ڤHeart Disease / ڤDrinking Problem / ڤOvarian Cancer
ڤStroke / ڤHigh Blood Pressure / ڤBreast Cancer / ڤColon Cancer
Have you had problems with any of the following within the past year?

General

ڤWeight Loss or Gain
ڤFevers
ڤTrouble Sleeping
ڤChronic Fatigue
ڤ Excessive Bleeding
ڤEasy Bruising
ڤAbnormal Thirst /

Lungs

ڤCoughing Up Blood
ڤShortness of Breath
ڤChronic Cough
ڤBlood Clot in the Lungs
ڤPainful Breathing
ڤWheezing /

Musculoskeletal

ڤMuscle Weakness
ڤJoint Pains
ڤJoint Swelling
ڤClot in Leg Vein /

Menstrual Problems

ڤCramps/Pain
ڤHeavy Bleeding
ڤToo Frequent Periods
ڤBleeding Between Periods
ڤMissed a Period
ڤOther Period Issue / Other Gynecologic Issues
ڤVaginal Discharge
ڤItching/Irritation
ڤVulvar Pain
ڤVulvar lump/growth
ڤVulvar Sores

Neurologic

ڤ Frequent/Severe Headaches
ڤDizziness
ڤSeizures
ڤNumbness
ڤTrouble Walking
ڤFainting Spells

Sexual Problems

ڤPainful Intercourse
ڤBleeding after Intercourse
ڤDecreased Desire
ڤOrgasm Problems
ڤDryness
ڤPossible Exposure to STD
ڤOther Sexual Issue

Cardiovascular

ڤChest Pain
ڤIrregular Heart Beat
ڤAnkle/Hand Swelling /

Pre Menstrual Problems

ڤBloating/Swelling
ڤMood Changes
ڤBreast Changes
ڤHeadaches
ڤAcne
ڤOther PMS Issue

Eyes

ڤItchy, Red Eyes
ڤVision Problems

Ears

ڤEar Pain
ڤRinging in Ears
ڤHearing Loss /

Gastrointestinal

ڤFrequent Diarrhea
ڤConstipation
ڤBloody Stools
ڤNausea/Vomiting
ڤHemorrhoids

Skin

ڤAcne
ڤUnwanted Hair Growth
ڤUnusual Lump or Growth
ڤDry Skin

Menopause Issues

ڤHot Flashes
ڤNight Sweats / Would you like to discuss any of the following?
ڤ Contraception
ڤMenopause Issues
ڤPregnancy Issues
ڤSelf Breast Exam
ڤSexuality Issues
ڤSTD’s
ڤOther

Nose

ڤSinus Problems
ڤNose Bleeds

Urinary

ڤIncomplete Urination
ڤLoss of Urine
ڤPainful Urination
ڤBloody Urine /

Emotional

ڤExcessive Worry
ڤDepression
ڤFrequent Crying
ڤSerious thoughts of harming yourself or others /

Breast Problems

ڤBreast Pain
ڤBreast Lump
ڤNipple Discharge
ڤOther Breast Issue

Mouth

ڤSore Throat
ڤMouth Sores
ڤDental Problems

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