CURRENT SCREENING-YEAR OF LAST

PAP

MAMMOGRAM

BONE DENSITY

COLONOSCOPY

NEW PATIENT MEDICAL HISTORY

PERSONAL PROFILE

NAMEName you would like us to use

DOB:

ADDRESS:

CITYSTATEZIP CODE

CONTACT INFORMATION:

HOME:CELL:WORK:

EMAIL:PREFER TO BE CONTACT BY:

PRIMARY LANGUAGE:INTERPRETER NEEDED:YESNO

GUARANTORINSURANCE

EMERGENCY CONTACT:RELATIONSHIP:PHONE #:

PHARMACY:

PRIMARY CARE DOCTOR:

REFERRED BY:

MARITAL STATUS:MSWD

LIVE IN RELATIONSHIP:YesNo

SAME SEX RELATIONSHIP:YesNo

OCCUPATION:

IF YOU ARE UNCOMFORTABLE WITH ANY QUESTIONS LEAVE THEM BLANK AND DISCUSS WITH YOUR PROVIDER

ALLERGIES: (include medications, foods, environmental)

FAMILY HISTORY

If living (L), please indicate state of health. If deceased (D), please indicate cause of death.

Father (age___)(L) _____(D) _____

Mother (age___) (L) _____(D) _____

Brothers (ages _____) (L) _____(D) _____

Sisters (ages ______)(L) _____(D) _____

Have any members of your immediate family had the following: (Mother, Father, Sisters, Brothers)

NoYesRelation

Cancer:

Breast______

Colon______

Ovarian______

Uterus______

Diabetes______

Endometriosis ______

Heart Disease ______

High Blood Pressure______

Kidney Disease______

Stroke______

DVT (blood clot in______

lungs or extremities)

Osteoporosis______

Hepatitis______

Birth defects______

Other______

IMMUNIZATIONS DONE: YES OR NO

TDAP Flu

Chicken PoxHepatitis B

MMR TB

Gardasil Shingles

OPERATIONS/HOSPITALIZATIONS

YEARTYPE OF SURGERYHOSPITAL

ANESTHESIA:

Have you had anesthesia in the past?YesNo

Any reactions to anesthesia?YesNo

TRANSFUSION:

Have you ever had a blood transfusion?YesNo

Are blood transfusions acceptable to patient?Yes No

PERSONAL MEDICAL HISTORY: Have you ever had: (please circle all that apply)

AsthmaCancerMRSA

Kidney diseaseEndometriosisVRE

Kidney stonesDepression/anxiety

Sexually transmitted diseasesMental illness

FibroidsBlood transfusions/accept?

TBSeizures

InfertilityMigraines

HIV/AIDSHepatitis/liver disease

Heart attack/heart diseaseOrthopedic problems

Heart defectJoint pain

HypertensionBirth defects

DiabetesStroke

Breast problemsBlood clots in lung or legs

ThyroidAutoimmune disease

Bowel disordersAlcohol/substance abuse

Abnormal PapAcne

Excessive hair growthIncontinence

Others ______

MEDICATIONS (include vitamins, herbal supplements)

Medication Allergies?YesNo______

Current Medications:

DrugDoseFrequency

SOCIAL HISTORY

Smoker:YesNoNeverFormer

Did any of your parents have a problem with alcohol or drug use?⃝ Yes ⃝ No

Do any of your friends/peers have a problem with alcohol or drug use?⃝ Yes ⃝ No

Does your partner have a problem with alcohol or drug use?⃝ Yes ⃝ No

In the past, have you had difficulties in your life due to alcohol or other drugs,

including prescription medications?⃝ Yes ⃝ No

Have you ever taken prescription medications for non-medical use?⃝ Yes ⃝ No

Recreational drugsYesNoCurrentMonthDay

Seat belt useYesNo

ExerciseYesNoDailyWeekly

Are you safe at home?YesNo

Are history of abuse or violence in your relationships? YesNo

GYN HISTORY

Menstrual cyclesor Menopausal

Date of last menstrual period:Age first menstrual period:

# of days:Cramps?YesNo

Any problems with menstrual periods:YesNo

Are you sexually active?YesNo

Sexual partners are:MenWomenBoth

Present method of birth control:

Do you have any concerns about sexual health or sexual interest?YesNo

OBSTETRICAL HISTORY

How many times have you been pregnant? _____ Any miscarriages? _____ Abortions? _____

MONTH/
YEAR / HOSPITAL-
MD / VAG/
OR C/S / #WKS
DEL. / WT / SEX / COMMENT/
COMPLICATIONS
______

QUESTIONS AND CONCERNS YOU HAVE:

______

WH B-2, Revised 3/2/17