Associates in Women's Health
Patient Medical History Form


None

Eggs

Latex

Iodine

Current Contraception (including tubal ligation, vasectomy, condoms, etc.)

What symptoms and concerns do you want to discuss?

Have you seen another provider for the same condition?

No

Yes

Yes

No

Normal

Abnormal

Normal

Abnormal

Never

Normal

Abnormal

Never

Normal

Abnormal

Never

  1. Current Medications (please include vitamins, herbal supplements, and over the counter medications)
  2. Obstetrical History
  3. Menstrual History
  4. Surgery and Hospitalization History (including C-sections)
  5. Gynecological History
  6. Social History
  7. Current Review of Systems (please check if you are now or recently have experienced any of the following)
  8. Past Illnesses
  9. Personal/Family History
  10. Vaccinations (have you had or have you been immunized against the following – include dates if possible)

Thank you for taking the time to complete your medical history!