Name:_______________________________________________________ Date:______________

FOR DOCTOR'S USE ONLY
PAST MEDICAL HISTORY
You
Your
Family
   
You
Your
Family
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
6. Breast problems
  16. Blood clots in legs or lungs
7. Jaundice, hepatitis, or
  liver problems
  17. Varicose veins or infected
  veins (phlebitis)
8. Stomach, bowel or gall
  bladder problems
  18. Infections in tubes or
  ovaries
9. Epilepsy or convulsions
  19. Gonorrhea or other
  venereal diseases
10. Kidney or bladder problems
  20. Other medical problems.

MEDICATION HISTORY
Yes 
No
21. Allergies or drug sensitivities
22. Presently taking medication

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  
  No  
Pain with periods
Bleeding between periods
Vaginal discharge

26. FAMILY PLANNING   Yes  
  Past  
No need
Birth control pills
Intrauterine device
Diaphragm
Foam
Condom, rubber
Sterilization       Male        Female     Yes  
  No  
Have you ever had complications with any type of birth control?
Do you have any questions about birth control?
Have you ever ha any difficulty becoming pregnant?

     Yes  
  No  
27. Do you smoke?
28. Do you lose any urine when you cough or sneeze?
29. Do you have any questions about venereal disease?
30. Do you have any questions or problems about sex that you would like to discuss?

 


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