New Patient History and Physical

Date______Physician Comments (Office Use Only) Name______PCP______CC:______Birth Date______Age______Referred by______HPI:______What is the reason for today’s visit?______Menstrual History ______Age of first period______Date of Last Period______Number of days between start of one period and the next______Number of days of flow____ Are periods regular? Yes/No ______Amount of flow Light/Medium/Heavy Are periods painful/crampy? Yes/No ______Do you have bleeding between periods? Yes/No After intercourse? Yes/No ______Gynecology History (Circle all problems in your past or present history) ______Abnormal Pap Date______Results______Treatment______Venereal Warts/ Condyloma ______Pelvic Inflammatory Disease Chlamydia Gonorrhea Syphilis Herpes ______Recurrent Vaginal Infections Recurrent Bladder Infections Urinary Leakage ______Ovarian Cysts Endometriosis Fibroid Uterus Infertility PCOS ______PMS: Depression/Anxiety Fluid Retention Breast Soreness ______Menopausal Symptoms: Hot Flashes Night Sweats Vaginal Dryness ______Sexually Active Yes/No Sexual Problems: Decreased Sex Drive Painful Sex ______Breast Problems: History of Cancer Discharge Abnormal Mammogram ______Past Biopsy: Date______Results______Implants Reduction ______Birth Control Method______Medical History (Check all problems in your past or present history) ______Chicken Pox ___ Chronic Lung Disease ___ Tuberculosis ______Asthma ___ Heart Disease ___ Hypertension ______High Cholesterol ___ Migraines ___ Seizures ______Stroke ___ Hepatitis/Jaundice ___ Ulcers/Reflux ______Kidney Stones ___ Diabetes ___ IBS ______Liver Disease ___ Anemia ___ Thyroid Disease ______Major Accident ___ Glaucoma ___ Blood Transfusion ______Cancer ___ Depression/Anxiety ___ Osteoporosis ______Review of Systems (Office Use Only) Constitutional: Weight Loss, Weight Gain, Fevers, Fatigue Musculoskeletal: Muscle Weakness, Joint Pains, Low Back Pain Eyes: Contacts/Glasses, Double Vision, Spots Before Eyes, Tunnel Vision Skin/Breast: Breast Pain, Discharge, Masses, Rash, Ulcers, Acne ENT: Ear Aches/ Ringing, Sinus Problems, Sore Throat/Mouth, Dental Problems Neurological: Dizziness, Seizure, Numbness, Trouble Walking CV: Palpitations, Chest Pain, Difficulty Breathing, Leg Swelling Psychiatric: Depression, Crying, PMS, Sleep Disorder, Eating Disorder Respiratory: Wheezing, Spitting up Blood, Shortness of Breath, Chronic Cough Endocrine: Dry Skin, Abnormal Thirst, Hair Loss, Facial Hair GI: Diarrhea, Nausea/Vomiting, Constipation, Hemorrhoids, Incontinence Hematologic/Lymphatic: Bruising, Enlarged Lymph Nodes, Bleeding Urinary: Blood, Pain, Urgency, Frequency, Incontinence, Incomplete Emptying Allergy/Immunologic: Environmental, Food, Immune Disorder New Patient History and Physical Obstetrical History Please fill out completely regardless of stage of life, including live births, still births, miscarriages, abortions, and tubal pregnancies. Date Pregnancy Length Labor Duration Sex Weight Delivery Type ______Surgical History Medications (Including Vitamins) Allergies (Medication/Type of Reaction) Year Procedure Medication Dosage ______Social History Screening Tests/Vaccines (List most recent date) Occupation______Pap Smear______Normal/Abnormal Marital Status: Single/Married/Widow/Divorced Mammogram______Normal/Abnormal Sexual Preference: Heterosexual/Homosexual/Bisexual Cholesterol______Normal/Abnormal Do you Exercise? Yes/No Type/Frequency______Colonoscopy______Normal/Abnormal Do you Smoke? Yes/No Number per day______EKG/Stress Test______Normal/Abnormal Do you drink Alcohol? Yes/No Number per week______Bone Density Test______Normal/Abnormal Do you use Recreational Drugs? Yes/No Type______TB Skin Test______Normal/Abnormal Do you wear your seatbelt in the car? Yes/No Rubella Immunity______Normal/Abnormal Do you have problems with Verbal/Physical Abuse? Yes/No Flu Vaccine______Do you follow a special diet? Yes/No Type______Pneumonia Vaccine______Family History Gardasil Vaccine______Please indicate which family members have the following conditions, past or present. Ovarian Cancer______Heart Disease______Breast Cancer______Melanoma______Uterine Cancer______Colon Cancer______Mom: Name______Alive/Deceased Age_____ Cancer/Heart Disease? Dad: Name______Alive/Deceased Age_____ Cancer/Heart Disease? Siblings: Name______Alive/Deceased Age_____ Cancer/Heart Disease? Name______Alive/Deceased Age_____ Cancer/Heart Disease? Name______Alive/Deceased Age_____ Cancer/Heart Disease? Name______Alive/Deceased Age_____ Cancer/Heart Disease? Please list any additional issues or comments you would like to address. ______