Royal Oaks OB/GYN
12121 Richmond Avenue, Suite 414
Houston, TX 77082
Phone: 281-496-DRVU (3788)
Fax: 281-496-3789
COMPLETE HISTORY FORM
Patient name: ______
Date of birth: ______
Today’s date: ______
What is the reason for your appointment? ______
______
______
Past/ Current medical conditions (please circle): None
High blood pressure Diabetes Thyroid disorder
Asthma Depression Seizure disorder
Heart attack Stroke Blood clot
Other: ______
______
______
Surgeries (please list): ______
______
______
Have you had any past problems with anesthesia? (please circle): Yes No
If your answer is “yes,” please explain: ______
______
______
Obstetrical history
Are you currently pregnant? (please circle): Yes No
# of times you have been pregnant (including the current pregnancy if applicable): ______
# of times you have delivered: ______
# of cesarean sections: ______
# of vaginal deliveries: ______
# of miscarriages: ______
# of elective abortions: ______
# of times you delivered twins/ multiple gestations: ______
# of living children: ______
Have you had your tubes tied? (please circle): Yes No
Has your significant other had a vasectomy? Yes No
Gynecological history
Have you had a hysterectomy? (please circle): Yes No
Do you still have monthly periods? (please circle): Yes No
When was your last menstrual period: ______
Describe your bleeding patterns (if applicable):
How often do you bleed? ______
How many days do your periods last? ______
Describe your overall flow (please circle):
Normal Light Moderate Heavy
Do you experience pain before/ during your periods? (please circle):
None Mild Moderate Severe
Are you satisfied with your bleeding pattern? (please circle): Yes No
Have you ever had an ABNORMAL pap smear? (please circle): Yes No
If you answered “yes,” did you have any of the following done? (please circle):
cervical biopsy cryotherapy (freezing) cold knife cone LEEP procedure other: ______
When was your last pap smear? ______
Have you ever had a sexually transmitted disease? (please circle): Yes No
If you answered “yes,” please specify: ______
______
______
Have you ever had an ABNORMAL mammogram? (please circle): Yes No
If you answered “yes,” did you undergo a breast ultrasound, biopsy, or other
procedure? (please circle): Yes ______No
When was your last mammogram? ______
Does anyone in your family have the following conditions? (please circle):
Breast cancer Other “female-type” cancers: ______
High blood pressure Diabetes Bleeding disorders
Other: ______
______
Have you ever used the following? (please circle & explain):
Tobacco: No Yes
Alcohol: No Yes
Recreational/ IV Drugs No Yes
Please elaborate on any “yes” responses: ______
Have you ever had a blood transfusion? (please circle): Yes No
Are you a Jehovah’s Witness? Yes No
Please list any drug allergies and specify the reaction(s): ______
______
______
______
List current medications (including over-the-counter & herbal drugs that you take as needed or on a regular basis):
Name Dose Frequency
______
(If you have a pre-printed list of your medications, we can make a Xerox copy for your records.)
We appreciate you taking the time to fill this form out accurately. This information helps us to help you! If your information ever changes, please let us know immediately. Thank you!
--Royal Oaks OB/GYN
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