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Medical History(Spanish)
Medical History(English)
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Medical History
Patient Name
Date of Birth
Date
What is the reason for your visit today?
Well Woman Exam – Pap smear, Breast Exam, STD Screening
I am pregnant
WKS
LMP:
Consult /Concern
Do you take any medications? ( If yes please list)
None
Name of Medication
Dosage
How Often
Date Started
Do you have any allergies?
None
Name of Allergen
Reaction
Date of 1st Reaction
Do you have any medical problems?
None
Medical Problem
Date of Diagnosis
Recent Lab Tests
Have you had any surgeries?
None
YEAR
PROCEDURE
HOSPITAL
Have you ever been hospitalized for more than one day?(Please List )
None
YEAR
NAME OF HOSPITAL
REASON
Sexual History
Are you sexually active?
Yes
No
Never
My sex partners are
Men
Women
Both
Number of sex partners this year
I have a new sex partner this year
Yes
No
Do you want to be tested for STD’S
Yes
No
Menstrual Cycle History
What was the first day of your last menstrual cycle?
/
/
Started at age
Regular
Irregular
Menopause
Regular
Irregular
Age menstrual cycle ended
Have you had post menopause bleeding?
Yes
No
Pregnancy List
How many times have you been pregnant?
How many live births?
How many? Vaginal Births
C-Sections
Abortions
Miscarriages
Stillbirths
Birth Control History
Have you ever taken birth control?
Yes
No
If yes, what type of birth control have you used?
Condoms
Birth Control Pills
Intrauterine Device (IUD)
Injection
Bilateral Tubal Ligation
Social History
Do you smoke?
No, Never
Former Smoker Yes,
Current Smoker, If former or current smoker:
packs per day
years
Do you drink?
No, Never
Former Smoker,
Yes
drinks per
week
Do you do drugs?
No, Never
Former Smoker,
Yes
Yes Name
How Long
week
Family History (Circle all that apply)
Mother
Alive
Deceased
Unknown
Healthy
Heart Disease
Cancer
Diabetes
High Blood Pressure
Father
Alive
Deceased
Unknown
Healthy
Heart Disease
Cancer
Diabetes
High Blood Pressure