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Microsoft word - new medical history.wps

MEDICAL HISTORY
Date________________________
Last Name First Name Middle Date of Birth


Address City County State Zip


Age Height Weight Race

Single_________
Married________

Your Phone Number You MUST provide us with your phone number and an emergency number


Emergency Phone Number Emergency Contact Person


Please check how you were referred to our clinic
Houston Yellow Pages

Houston White Business Pages
Spanish Yellow Pages
Any Phone Book other than Houston
Physician__________________
Friend/Former Patient
Name of City____________________
Clinic_____________________
Internet
PERSONAL HISTORY
Have you ever had or needed treatment for:
yes no

a. Vaginal infection or Discharge
n. Bleeding Tendencies (Hemorrhage)
b. Sexually Transmitted Disease (Syphilis, Gonorrhea,
o. Lung Disease (Asthma, pneumonia,
Trichomoniasis Herpes Chlamydia)
tuberculosis)
c. Uterine Fibroids
p. Anemia or Sickle Cell
d. Retroverted (tilted) Uterus
q. Liver Disease (Jaundice, hepatitis)
e. Kidney or Bladder Infection
r. Rheumatic Fever
f. Recent flu or high fever
s. Epilepsy Seizures
g. Severe Abdominal Pain
t. Diabetes
h. Breast Disease or Cancer
u. Blurring of Vision or severe headaches
i. Cervical Conization or Cryocauterization
v. Unexplained Bruising
j. Antibiotics in the past month
w. Dizzy or Fainting Spells
k. High or Low Blood Pressure or Heart Disease or Murmur
x. Severe Depression
l. Blood Clots or Phlebitis
y. Joint Disease
m. Needed a blood transfusion
z. Chronic Diarrhea or Constipation

If you have answered YES to any of the above, please identify by using the appropriate letter and follow with brief explanation:


Do you or any of your family members have any history of complications with anesthesia? If so, please describe


Please list previous hospitalizations for surgery:


Yes No
Do you drink alcohol?

if YES how many drinks per day?
per week?

Do you smoke?
if YES how many packs per day?
Do you take Ibuprofen or Aspirin on a regular basis
if Yes how often?
Have you taken any prescription/non prescription,
if YES name the medication or drugs
time taken?
legal/illegal drugs within 24 hours?

At what time did you last eat or drink (including water) _____________a.m. __________________p.m.

MEDICAL HISTORY PAGE 2

Name _________________________________________________________Date of birth______________

Last First Middle
Please check any medications listed below to which you HAVE HAD an allergic reaction:
Penicillin

Tetracycline Valium Demerol Lidocaine
Adhesive
Ampicillin
Xylocaine
Aspirin Betadine
Phenergan
Erythromycin
Nubain Tylenol Tetanus
MENSTRUAL HISTORY

____________LMP(first day of your last normal period)

Was this a normal period? ____Yes

At approximately what age did your menstrual periods begin____

How many days does your period usually last ?____

Are your periods

_____regular (usually at the same time each
____irregular (skip around each month)

yes no yes no
Do you have tension before a period?

Do you experience depression before a period?
Do you have cramps with a period?
Do you have pain with a period?
Do you have hot flashes?
Is it possible that you are pregnant at this time?
PREGNANCIES
DO NOT INCLUDE THIS PREGNANCY

Number of Previous Pregnancies

Number of Miscarriages
Number of Full Term Pregnancies
Number of Abortions
Number of Premature Births
Number of Cesareans
Number of Ectopic Pregnancies

Did you have excessive bleeding after any of the above?


Birthdate of youngest child, if applicable___________

BIRTH CONTROL
Are you using a birth control method? If yes, please check:
Birth Control Pills

Tubal Ligation
Birth Control Patch
Diaphragm/Cap
Depo-Provera
Withdrawal
Norplant

Would you like us to assist you in obtaining a birth control method? [ ] yes [ ] no

FAMILY HISTORY
Use appropriate letter for family members if any of the following illnesses apply:
Mother (M) Father (F) Sister (S) Brother (B)
Heart Disease
Tuberculosis
Diabetes

Mental Disease
Arthritis

What gynecological service can we provide you with this office visit?

__Abortion
__Sono __D&C __other

Source: http://www.texasabortioninformation.com/medical_history.pdf

17x24_3

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