NORTHLAND WOMEN’S HEALTH CARE, P.C. Chart Number:

Patient Information: (to be completed by patient) Date:

Name:

DOB:

Marital Status: Married Single Divorced Separated Widowed

Occupation:

Education:

History of: Tobacco Use Current Amount Years of use

Alcohol Use Current Amount

Drug Use Current Type & Amount

Family History:

Please state if each family member is living or deceased, current age or age at death, any major medical problems or cause of death.

Please continue on second line if needed.

Your mother:

cont:

Your father:

cont:

Your mother’s mother:

cont:

Your mother’s father:

cont:

Your father’s mother:

cont:

Your father’s father:

cont:

Your brothers and sisters:

cont:

Your children:

cont:

Please list known close blood relatives with any of the following problems:

Breast Cancer:

cont:

Ovarian Cancer:

cont:

Endometrial Cancer:

cont:

Colon Cancer:

cont:

High Blood Pressure:

cont:

Heart Disease/High Cholesterol:

cont:

Osteoporosis:

cont:

Blood Disorders/Bleeding Problems:

cont:

Diabetes:

cont:

Twins, Triplets:

cont:

Congenital, Genetic, or Birth Defects:

cont:

Obstetric History: Number of pregnancies: Premature births: Miscarriages: Abortions:

Living children

OBSTETRICAL HISTORY NO. OF PREGNANCIES---(complete below if applicable)

BORN
YEAR/MO / WEEKS
PREG. / WT. / SEX / TYPE OF
DELIVERY / REMARKS / BORN
YEAR/MO / WEEKS
PREG. / WT. / SEX / TYPE OF
DELIVERY / REMARKS
1. / N/AFemaleMale / N/AVaginalC-Section / 4. / N/AFemaleMale / N/AVaginalC-Section
2. / N/AFemaleMale / N/AVaginalC-Section / 5. / N/AFemaleMale / N/AVaginalC-Section
3. / N/AFemaleMale / N/AVaginalC-Section / 6. / N/AFemaleMale / N/AVaginalC-Section
PAST MEDICAL HISTORY / PLEASE CHECK ( ) IF YOU HAVE HAD ANY OF THE FOLLOWING CONDITIONS
1. WEIGHT LOSS-GAIN / 19. SKIN DISEASE
2. HEADACHES/MIGRAINES / 20. THYROID DISORDER
3. HEART DISEASE / 21. DIABETES
HEART MURMUR / GESTATIONAL
4. HIGH BLOOD PRESSURE / 22. CANCER (TYPE)
5. HIGH CHOLESTEROL / (TYPE)
6. RESPIRATORY DISEASE / 23. EPILEPSY/NEUROLOCIAL DISORDER
(LUNG) ASTHMA / 24. ARTHRITIS – JOINT PAIN
7. BREAST DISEASE / 25. OSTEOPOROSIS
8. JAUNDICE/HEPATITIS / 26. AUTOIMMUNE DISEASE
9. HIATAL HERNIA (REFLUX) / 27. OVARIAN CANCER
10. STOMACH ULCERS / 28. ENDOMETRIOSIS
11. BOWEL DISEASE / 29. ECTOPIC PREGNANCY
COLON CANCER / 30. FIBROIDS
12. KIDNEY DISEASE / 31. INFERTILITY
13. URINARY INCONTINENCE / 32. UTERINE/CERVICAL ABNORMALITY
14. URINARY INFECTIONS / 33. ANXIETY/DEPRESSION
15. BLOOD DISORDERS / 34. SLEEP PROBLEMS
16. BLOOD TRANSFUSIONS / 35. ABUSE/DOMESTIC VIOLENCE
17. VARICOSE VEINS / 36. OTHER
18. BLOOD CLOTS

Hospital Admissions/Surgeries(please list with dates and reason):

cont:

Menstrual History: Age at first period: Age at menopause:

Vaginal Infection / Sexually Transmitted Infection History: Please check if you have ever had any of the following:

Chronic Yeast Infections Trichomonas Chronic Bacterial Vaginosis Chlamydia Herpes Gonorrhea

Syphilis Pelvic Inflammatory Disease Human Papilloma Virus (HPV, Warts) Other

(If you find any of the Sexual History questions particularly offensive, leave blank and discuss with your Provider)

Sexual History: Have you ever had sex?Age at first sexual experienceNumber of lifetime partners

Are you currently sexually active? Do you have sex with males females both?

Contraceptive History: Please list your current method of contraception:

List other methods you have used:

Pap Smear History: Date of last Pap Smear: Any history of abnormal Pap?

Please list any treatments you have had for abnormal Paps: