Update Patient History InformationToday’s Date:

Last Name: ______First Name: ______Date of Birth: ______

Reason for today’s visit: Annual GYN Visit______Other: ______

______

New past medical/surgical history in last three years: (Surgeries, Hospitalizations, and Illness) NONE: ______

Type: ______Date:______Doctor/Location:______

Type: ______Date:______Doctor/Location:______

Any significant changes to family history? ______yes ______no

New health care maintenance updates, within last three years: NONE:______

Last Pap: ______Last Mammogram: ______Last Colonoscopy______Last Dexa Scan______Last Annual Labs______

Please list current medications, supplements, including dose and frequency

Name: / Dose: / Frequency:

Allergies ______noyes______if yes please list

Allergen / Reaction

Reproductive History

First Day of last period ______Interval between period______Menopausal or Hysterectomy______

Do you have pain with periods ______yes ______no Do you have bleeding between periods______

Do you use any type of contraception/pregnancy prevention, if so list: ______

Type: ______

Pregnancy History: Any changes? ______yes ______no

Total # of Pregnancy / # of miscarriages / # of abortions / # of deliveries / # of living children

See reverse side to complete:

Patient Signature: ______

Social History

Do you smoke cigarettes / Yes / No / Amount
Do you drink alcohol / Yes / No / Amount
Do you consume caffeine / Yes / No / Amount
Do you use recreational drugs / Yes / No / Amount
Do you exercise? Yes no / How often per week
Do you feel safe at home? Yes No / Do you feel safe in current relationship Yes No

REVIEW OF SYSTEMS-IN THE LAST 30 DAYS HAVE YOU EXPERIENCED: PLEASE CIRCLE IF YES

CONSTITUTIONAL:

Fatigue / Fever / Chills / Body Aches / Night Sweats / Weight. Gain/Loss / Appetite Loss

HEAD-EARS-NOSE-THROAT:

Headaches / Lightheadedness
Fainting / Recent Head Injury / Visual Disturbance / Nose Bleeding / Nasal Discharge
Decreased Hearing / Sinus Pain/Symptoms / Dental Problems / Ringing in ears

BREASTS:

Lumps / Tenderness / Dimpling / Abnormal changes in size / Redness / Nipple discharge / Swelling

CARDIOVASCULAR:

Chest Pain / Irregular Heart Beat / Rapid Heart Beat / Leg/Ankle/Foot Swelling / Varicosities

RESPIRATORY:

Shortness of Breath / Hoarseness / Wheezing / TB Exposure / Cough

GASTROINTESTIONAL:

Nausea / Hemorrhoids / Abdominal Pain / Diarrhea / Constipation / Vomiting / Bloating
Jaundice / Stool changes / Heartburn

GENITOURINARY/ENDOCRINE:

Urine Urgency / Difficulty Urinating / Urinary Frequency / Pain with Urination / Blood in Urine / Leakage of Urine / Pain with Intercourse
Heavy Bleeding with Periods / Bleeding After Intercourse / Significant PMS Symptoms / Genital Sores / Excessive Thirst

INTEGUMENTARY:

Rash / New Skin Lesions / Itching / Change in Lesions/Moles / Skin Dryness / Acne / Hair Growth Change

NEUROLOGICAL:

Muscular Weakness / Seizures / Tingling/Numbness / Loss of Balance / Difficulty concentrating / Memory Difficulties

PHYCHIATRIC

Depression / Anxiety / Difficulty Sleeping / Thoughts of Hurting Yourself

HEMATOLOGY-LYMPHATIC

Lymph Node Enlargement or Tenderness / Easy Bruising

ALLERGIC-IMMUNOLOGIC:

Hay Fever/Seasonal Allergies / Hives / Frequent Illness