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?

Please list any additional issues or comments you would like to address.

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