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:
DateMo/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
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Mother
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Brother/Sister 1
2
3
4
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Husband
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BLOOD RELATIVES WITH RELATIONSHIP AGE AT ONSET
Breast Cancer
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Ovarian Cancer
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Uterine Cancer
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Colon Cancer
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Diabetes
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Heart Disease
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High Blood Pressure
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Epilepsy/Seizures
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Stroke
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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