Date _____________________ History # ________________ SSN ________________

Name _______________________________ Age ____ Date of Birth _____________

Address _______________________________________________________________

Phone (h) ________________ (w) ________________ (cell) ________________

Marital Status:   S   M   D   W   Husband's Name (optional) _____________________

Provider Review / Date ___________________________________________________

MEDICAL HISTORY - Have you had any of the following?

	Yes	No	Year		Yes	No	Year
Abnormal pap smear	_____	_____	_____	HIV	_____	_____	_____
Allergies	_____	_____	_____	Irregular bleeding	_____	_____	_____
Anemia	_____	_____	_____	Kidney problems	_____	_____	_____
Bleeding disorder	_____	_____	_____	Lung disease	_____	_____	_____
Blood cots in legs	_____	_____	_____	Menopausal symptoms	_____	_____	_____
Blood transfusions	_____	_____	_____	Mononucleosis	_____	_____	_____
Breast Discharge	_____	_____	_____	Ovarian cysts	_____	_____	_____
Breast lumps	_____	_____	_____	Pelvic infections	_____	_____	_____
Cancer (type)	_____	_____	_____	Psychiatric problems	_____	_____	_____
Chest pain	_____	_____	_____	Sexually trasmitted
Colonoscopy	_____	_____	_____	infections	_____	_____	_____
DEXA (bone scan)	_____	_____	_____	Sickle cell anemia	_____	_____	_____
Diabetes	_____	_____	_____	Stomach problems	_____	_____	_____
Fainting spells	_____	_____	_____	Stroke	_____	_____	_____
Gall bladder disease	_____	_____	_____	Thyroid problems	_____	_____	_____
Headaches (severe)	_____	_____	_____	Urinary tract infections	_____	_____	_____
Heart murmur	_____	_____	_____	Vision problems	_____	_____	_____
Hepatitis	_____	_____	_____	Vaginal discharge	_____	_____	_____
High blood pressure	_____	_____	_____	Other	_____	_____	_____

Dates and types of surgery ________________________________________

________________________________________________________________________

Dates and reasons for hospitalizations ________________________________

________________________________________________________________________

Names and dosages of any medication you are currently taking (including over the counter)

________________________________________________________________________

FAMILY HISTORY

Are you adopted?  Yes _____  No _____

If no, do you have a family history of the following?

_____	Breast cancer	_____	Other cancers
_____	Osteoporosis	_____	Strokes
_____	Diabetes	_____	Heart attacks
_____	High blood pressure	_____	Other; what?	_____________________________

SOCIAL HISTORY - Have you ever had a problem with the following?

	Yes	No	Current
Alcohol abuse	_____	_____	_____
Cigarette smoking	_____	_____	_____
Drug abuse	_____	_____	_____
Sexual abuse / rape	_____	_____	_____
Sexual problems	_____	_____	_____
Physical abuse	_____	_____	_____

MENSTRUAL HISTORY

Age periods started ____________  Regular _____  Irregular ______

Age periods ended ____________ (if menopausal or hysterectomy)

How often do periods come? _____________  How many days do they last? _________

First day of last normal period ___________

Any problems with periods? ______________________________________________

CONTRACEPTIVE HISTORY - Have you used the following?

	Yes	No	Year
IUD	_____	_____	_____	Female Sterilization	_____	_____	_____
Pills	_____	_____	_____	Male Sterilization	_____	_____	_____
Diaphragm	_____	_____	_____	Hysterectomy	_____	_____	_____
Condoms	_____	_____	_____	Abstinence	_____	_____	_____
Sponge	_____	_____	_____	Other	_____	_____	_____
Injectables (DEPO)	_____	_____	_____

PREGNANCY HISTORY

Number of pregnancies ________  Live births ____________

Miscarriages _______  Abortions _________  Ectopic ________

Date	Pregnancy outcome	Problems?
____________	________________________	_____________________________________
____________	________________________	_____________________________________
____________	________________________	_____________________________________
____________	________________________	_____________________________________

Please tell us why you are here today ___________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

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