<p> Westlake Gynecology & Women’s Healthcare</p><p>PATIENT MEDICAL DATA</p><p>Name______Age______DOB______S M D W Date______</p><p>Preferred Name______Home Phone______Cell Phone______Occupation______Reason for visit: Referral ______Routine _____or other: ______</p><p>Circle all that apply to you: Pre-menopause Peri-menopause Menopausal Hysterectomy</p><p>Number of: Pregnancies ______Deliveries ______Miscarriages ______Abortions ______Ectopic ______</p><p>Date of last Menses:______Cycle length:______Duration ______Pain: Y____N____ Heavy: Y____N____</p><p>#of Children _____Ages:______# of Vaginal Births _____ #of C-Sections ______#of Premature Births_____</p><p>My last pap smear date: ______normal: Y___ N___ My last mammogram date: ______normal: Y___ N___</p><p>MEDICAL HISTORY (circle all that apply past or present):</p><p>Acne Colitis Endometriosis Heavy Bleeding Irritable Bowel Pelvic Pain</p><p>Anxiety Depression Epilepsy Hepatitis Kidney Stones Stroke</p><p>Arthritis Diabetes Fibrocystic Breasts HPV Migraines Thyroid Problems</p><p>Asthma Dysplasia Genital Warts Hypertension Obesity Urinary Leakage</p><p>Blood Clots Emphysema Heart Disease Infertility Osteoporosis</p><p>Other Conditions or cancer history (list specific organ/satage/treatment):______</p><p>______</p><p>SURGERY (list organs/ types of procedures/ year performed/minor gyn procedures/ovarian/uterine):______</p><p>______</p><p>ALLERGIES (circle below or list / specify reaction; rash, swelling, loss of breath):______</p><p>Penicillin Sulfa erythromycin Codeine Iodine tapes List any other allergies______</p><p>______</p><p>MEDICATIONS (list names and doses of prescriptions, vitamins, herbal products, supplements):______</p><p>______</p><p>______</p><p>Tobacco use: ______ppd:______Past/ Present Alcohol use:______Drug use:______IV Drugs______</p><p>Anesthesia problems: ______Concerns about HIV or Hepatitis? ______</p><p>FAMILY HISTORY (circle or list those only in your immediate family- parents/siblings):</p><p>Arthritis Endometriosis Heart Attack Stroke Cancer: Breast Colon Ovary Uterus</p><p>Depression Fibroids Melanoma Thyroid Other Cancers: ______</p><p>Diabetes Genetic Disease Osteoporosis ______</p><p>Are you or have you been sexually active? Y N</p><p>Current Contraception (circle all that apply): Condoms OC Pills Diaphragm Depo-Provera Tubal</p><p>Abstinence IUD Withdrawal Vasectomy None N/A</p><p>Are you interested in a new form of contraception? Y___ N___ Maybe___ Do you want to get pregnant? Y___ N___</p><p>My most important health issue is routine screening or______</p>