Westlake Gynecology & Women S Healthcare

Westlake Gynecology & Women’s Healthcare

PATIENT MEDICAL DATA

Name______Age______DOB______S M D W Date______

Preferred Name______Home Phone______Cell Phone______Occupation______Reason for visit: Referral ______Routine _____or other: ______

Circle all that apply to you: Pre-menopause Peri-menopause Menopausal Hysterectomy

Number of: Pregnancies ______Deliveries ______Miscarriages ______Abortions ______Ectopic ______

Date of last Menses:______Cycle length:______Duration ______Pain: Y____N____ Heavy: Y____N____

#of Children _____Ages:______# of Vaginal Births _____ #of C-Sections ______#of Premature Births_____

My last pap smear date: ______normal: Y___ N___ My last mammogram date: ______normal: Y___ N___

MEDICAL HISTORY (circle all that apply past or present):

Acne Colitis Endometriosis Heavy Bleeding Irritable Bowel Pelvic Pain

Anxiety Depression Epilepsy Hepatitis Kidney Stones Stroke

Arthritis Diabetes Fibrocystic Breasts HPV Migraines Thyroid Problems

Asthma Dysplasia Genital Warts Hypertension Obesity Urinary Leakage

Blood Clots Emphysema Heart Disease Infertility Osteoporosis

Other Conditions or cancer history (list specific organ/satage/treatment):______

______

SURGERY (list organs/ types of procedures/ year performed/minor gyn procedures/ovarian/uterine):______

______

ALLERGIES (circle below or list / specify reaction; rash, swelling, loss of breath):______

Penicillin Sulfa erythromycin Codeine Iodine tapes List any other allergies______

______

MEDICATIONS (list names and doses of prescriptions, vitamins, herbal products, supplements):______

______

Tobacco use: ______ppd:______Past/ Present Alcohol use:______Drug use:______IV Drugs______

Anesthesia problems: ______Concerns about HIV or Hepatitis? ______

FAMILY HISTORY (circle or list those only in your immediate family- parents/siblings):

Arthritis Endometriosis Heart Attack Stroke Cancer: Breast Colon Ovary Uterus

Depression Fibroids Melanoma Thyroid Other Cancers: ______

Diabetes Genetic Disease Osteoporosis ______

Are you or have you been sexually active? Y N

Current Contraception (circle all that apply): Condoms OC Pills Diaphragm Depo-Provera Tubal

Abstinence IUD Withdrawal Vasectomy None N/A

Are you interested in a new form of contraception? Y___ N___ Maybe___ Do you want to get pregnant? Y___ N___

My most important health issue is routine screening or______