Name:_______________________________________________________ | Date:______________ |
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FOR DOCTOR'S USE ONLY |
PAST MEDICAL HISTORY |
You
|
Your
Family |
You
|
Your
Family |
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1. Headaches | 11. Anemia or blood disorders | |||||
2. A thyroid problem | 12. A blood transfusion | |||||
3. A heart condition or rheumatic fever. |
13. Diabetes | |||||
4. High blood pressure | 14. Cancer | |||||
5. A lung disorder, asthma, or tuberculosis |
15. Birth defects or inherited diseases |
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6. Breast problems | 16. Blood clots in legs or lungs | |||||
7. Jaundice, hepatitis, or liver problems |
17. Varicose veins or infected veins (phlebitis) |
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8. Stomach, bowel or gall bladder problems |
18. Infections in tubes or ovaries |
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9. Epilepsy or convulsions | 19. Gonorrhea or other venereal diseases |
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10. Kidney or bladder problems | 20. Other medical problems. |
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MEDICATION HISTORY |
Yes
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No
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21. Allergies or drug sensitivities |
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22. Presently taking medication |
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23. SURGERY OR OTHER HOSPITALIZATIONS |
Year | Illness or operation | Complications? |
24. OBSTETRICAL HISTORY List the number of Pregnancies_______ Premature births_______ Miscarriages_______ Abortions_______ Living children_______ |
No. |
Year |
Baby
Weight |
Sex |
Months
preg. |
Normal
delivery? |
Complications? |
1 | ||||||
2 | ||||||
3 | ||||||
4 | ||||||
5 |
25. MENSTRUAL HISTORY Date of last period_______ Age at onset of periods_______ Days between periods_______ Length of bleeding_______ |
Yes |
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Pain with periods |
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Bleeding between periods |
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Vaginal discharge |
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26. FAMILY PLANNING | Yes |
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No need |
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Birth control pills |
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Intrauterine device |
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Diaphragm |
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Foam |
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Condom, rubber |
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Sterilization Male Female | Yes |
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Have you ever had complications with any type of birth control? |
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Do you have any questions about birth control? |
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Have you ever ha any difficulty becoming pregnant? |
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Yes |
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27. Do you smoke? |
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28. Do you lose any urine when you cough or sneeze? |
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29. Do you have any questions about venereal disease? |
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30. Do you have any questions or problems about sex that you would like to discuss? |
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