New Patient Health History – Associates In Women's Health

Associates in Women's Health
Patient Medical History Form

Date

Name:

Preferred Name:

DOB:

Primary Care MD/Clinic:

Referring MD:

Medication Allergies/Reactions:

None

Eggs

Latex

Iodine

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

Date of last annual exam:

First day of last menstrual period:

What symptoms and concerns do you want to discuss?

Have you seen another provider for the same condition?

Yes

Pap Smear:

Please list date of last pap smear

Have you ever had an abnormal pap smear?

Yes

Date/Treatment

Normal

Abnormal

Mammogram:

Please list date of last mammogram

Normal

Abnormal

Never

Colonoscopy:

Please list date of last colonoscopy

Normal

Abnormal

Never

Bone Density:

Please list date of last bone density

Normal

Abnormal

Never

1. Current Medications (please include vitamins, herbal supplements, and over the counter medications)

Medication/Strength	Dosage	Prescribing MD/NP/PA

2. Obstetrical History

Have you had any miscarriages?

Yes

Have you had any terminations?

Yes

Date	Child’s Sex/Name	Birth Weight	Labor Length	Vaginal/Cesarean	MD/Hospital	Complications

3. Menstrual History

Age at Onset (your first period):

Frequency:

Days of Flow:

Heavy Flow

Bleeding Between Periods

Bleeding After Intercourse

Menstrual Cramping

PMS

Menopause (age):

Surgical Menopause (date):

4. Surgery and Hospitalization History (including C-sections)

No changes since last completed form

Date	Surgery	MD/Hospital	Complications

9. Personal/Family History

No changes since last completed form

Please include yourself, immediate family, grandparents, aunts and uncles

	Self	Family	Relationship	Age Diagnosed
Breast Cancer
Ovarian Cancer
Endometrial Cancer
Colon Cancer
Colon Polyps
Ulcerative Colitis
Other Cancers (list type)
High Blood Pressure
Heart Disease/Angina
Elevated Cholesterol
Osteoporosis/Arthritis
Broken Hip/Spine
Diabetes
Kidney Disease
Mental Illness
Substance Abuse
Blood Clots/Thrombosis
Problems with Anesthesia
Thyroid Problems
Other

Patient’s Signature

Date

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

Associates in Women's Health
Patient Medical History Form

Please Fill Yellow Colored Fields. *Mandatory

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)

Please see these two links to maps and instructions on how to get to Southdale Hospital for Labor and Delivery.

Associates in Women's HealthPatient Medical History Form

Please Fill Yellow Colored Fields. *Mandatory

Associates in Women's Health
Patient Medical History Form