Gynecologic History

Date of last Physical Exam

Date of Positive Pregnancy Test

Age of First Period

Frequency of Menses

Date of Last Menstrual Period

Menstrual Problems

Menstrual Freewrite

Last Pap

Previous Abnormal Pap Tests

Pap Freewrite

Abnormal Bleeding

Abn Bleeding Freewrite

Method of Birth Control

Birth Control Problems

Birth Control Freewrite

Sterilization

History of Breast Problems/Disease?

Breast Problems Freewrite

History of Sexually Transmitted Disease or bacterial infections?

Infections Freewrite

History of Endometriosis?

What Treatments

History of Infertility?

What tests and/or treatments

History of Female Cancer

Cancer Freewrite

History of Alcohol Abuse?

If yes, details

History of Domestic Violence?

Relationship to you

DES Exposure

Obstetric History

Year

City/State

Length of Pregnancy

Hours in Labor

Complications of Pregnancy/Labor

Type of Delivery

Sex M/F

Birth Weight(s)

Year

City/State

Length of Pregnancy

Hours in Labor

Complications of Pregnancy/Labor

Type of Delivery

Sex M/F

Birth Weight(s)

Year

City/State

Length of Pregnancy

Hours in Labor

Complications of Pregnancy/Labor

Type of Delivery

Sex M/F

Birth Weight(s)

Year

City/State

Length of Pregnancy

Hours in Labor

Complications of Pregnancy/Labor

Type of Delivery

Sex M/F

Birth Weight(s)

Year

City/State

Length of Pregnancy

Hours in Labor

Complications of Pregnancy/Labor

Type of Delivery

Sex M/F

Birth Weight(s)

Year

City/State

Complications of Pregnancy/Labor

Hours in Labor

Length of Pregnancy

Hours in Labor

Sex M/F

Type of Delivery

Year

City/State

Length of Pregnancy

Hours in Labor

Complications of Pregnancy/Labor

Type of Delivery

Sex M/F

Birth Weight(s)

Year

City/State

Length of Pregnancy

Hours in Labor

Complications of Pregnancy/Labor

Type of Delivery

Sex M/F

Birth Weight(s)

Surgical History

Year

City/State

Type of Surgery

Type of Surgery Freewrite

Complications

Year

City/State

Type of Surgery

Type of Surgery Freewrite

Complications

Year

City/State

Type of Surgery

Type of Surgery Freewrite

Complications

Year

City/State

Type of Surgery

Type of Surgery Freewrite

Complications

Year

City/State

Type of Surgery

Type of Surgery Freewrite

Complications

Year

City/State

Type of Surgery

Type of Surgery Freewrite

Complications

Year

City/State

Type of Surgery

Type of Surgery Freewrite

Complications

Year

City/State

Type of Surgery

Type of Surgery Freewrite

Complications

Health Maintenance

Cholesterol Screening

Date

Results

Mammogram

Date

Results

Colonoscopy

Date

Results

Bone Density Scan

Date

Results

Patient's diet

Caffeine

Tobacco

Quite Date

Alcohol

Drinks per Week

Excercise

Times Per Week

Vitamins and /or Calcium Supplements

Recreational Drug Use

Drugs

Have you used or shared needles?

Current Medications

Present Medications

Dosage and Frequency

Prescribing Physician

Present Medications

Dosage and Frequency

Prescribing Physician

Present Medications

Dosage and Frequency

Prescribing Physician

Present Medications

Dosage and Frequency

Prescribing Physician

Present Medications

Dosage and Frequency

Prescribing Physician

Present Medications

Dosage and Frequency

Prescribing Physician

Medical Allergies

Medical Allergies

Medication

Reactions

Medication

Reactions

Medication

Reactions

Medication

Reactions

Medication

Reactions

Medical History

Are you adopted?

Cardiovascular Disease (Heart)

Comments

Pulmonary Disease

Comments

Endocrine Disease

Comments

Gastrointestinal Disease

Comments

Bladder/Kidney Infections

Comments

Neurological Problems

Comments

Hematologic (Blood) Disease

Comments

Musculoskeletal Disorders

Comments

Psychiatric/Emotional Problems

Comments

Genetic (inherited) or Congenital Diseases

Comments

Other Autoimmune Disease

Comments

History of Cancer

Comments

Family History

Father's Medical History

Cardiovascular Disease (Heart)

Pulmonary Disease

Endocrine Disease

Gastrointestinal Disease

Bladder/Kidney Infections

Neurological Problems

Hematologic (Blood) Disease

Musculoskeletal Disorders

Psychiatric/Emotional Problems

Genetic (inherited) or Congenital Diseases

Other Autoimmune Disease

History of Cancer

Any others not listed above

Mother's Medical History

Cardiovascular Disease (Heart)

Pulmonary Disease

Endocrine Disease

Gastrointestinal Disease

Bladder/Kidney Infections

Neurological Problems

Hematologic (Blood) Disease

Musculoskeletal Disorders

Psychiatric/Emotional Problems

Genetic (inherited) or Congenital Diseases

Other Autoimmune Disease

History of Cancer

Any others not listed above

Sibling's Medical History

Cardiovascular Disease (Heart)

Pulmonary Disease

Endocrine Disease

Gastrointestinal Disease

Bladder/Kidney Infections

Neurological Problems

Hematologic (Blood) Disease

Musculoskeletal Disorders

Psychiatric/Emotional Problems

Genetic (inherited) or Congenital Diseases

Other Autoimmune Disease

History of Cancer

Any others not listed above

Maternal Grandparent's Medical History

Cardiovascular Disease (Heart)

Pulmonary Disease

Endocrine Disease

Gastrointestinal Disease

Bladder/Kidney Infections

Neurological Problems

Hematologic (Blood) Disease

Musculoskeletal Disorders

Psychiatric/Emotional Problems

Genetic (inherited) or Congenital Diseases

Other Autoimmune Disease

History of Cancer

Any others not listed above

Paternal Grandparent's Medical History

Cardiovascular Disease (Heart)

Pulmonary Disease

Endocrine Disease

Gastrointestinal Disease

Bladder/Kidney Infections

Neurological Problems

Hematologic (Blood) Disease

Musculoskeletal Disorders

Psychiatric/Emotional Problems

Genetic (inherited) or Congenital Diseases

Other Autoimmune Disease

History of Cancer