You
Your
Family
Family
You
Your
Family
Family
rheumatic fever.
tuberculosis
inherited diseases
liver problems
veins (phlebitis)
bladder problems
ovaries
venereal diseases
| Name:_______________________________________________________ | Date:______________ |
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FOR DOCTOR'S USE ONLY |
| PAST MEDICAL HISTORY |
You
|
Your
Family |
You
|
Your
Family |
||
| 1. Headaches |
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11. Anemia or blood disorders |
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| 2. A thyroid problem |
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12. A blood transfusion |
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| 3. A heart condition or rheumatic fever. |
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13. Diabetes |
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| 4. High blood pressure |
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14. Cancer |
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| 5. A lung disorder, asthma, or tuberculosis |
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15. Birth defects or inherited diseases |
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| 6. Breast problems |
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16. Blood clots in legs or lungs |
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| 7. Jaundice, hepatitis, or liver problems |
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17. Varicose veins or infected veins (phlebitis) |
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| 8. Stomach, bowel or gall bladder problems |
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18. Infections in tubes or ovaries |
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| 9. Epilepsy or convulsions |
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19. Gonorrhea or other venereal diseases |
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| 10. Kidney or bladder problems |
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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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