Medical History
Patient Name Date of Birth Date
What is the reason for your visit today?
WKS LMP:
Do you take any medications? ( If yes please list)
Name of Medication Dosage How Often Date Started
Do you have any allergies?
Name of Allergen Reaction Date of 1st Reaction
Do you have any medical problems?
Medical Problem Date of Diagnosis Recent Lab Tests
Have you had any surgeries?
YEAR PROCEDURE HOSPITAL
Have you ever been hospitalized for more than one day?(Please List )
YEAR NAME OF HOSPITAL REASON
Sexual History
Menstrual Cycle History
What was the first day of your last menstrual cycle? / / Started at age
Menopause
Age menstrual cycle ended Have you had post menopause bleeding?
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?
If yes, what type of birth control have you used?
Social History
Do you smoke?
Current Smoker, If former or current smoker: packs per day years
Do you drink?
Yes drinks per week
Do you do drugs?
Yes Name How Long week
Family History (Circle all that apply)
Mother
Father