Patient Medical History Form PDF
Patient Name ________________________________ Date of Visit ____/_____/_____
Age _____ Weight ________ lbs ________ kg Height ________ ft/in
Reason(s) for today’s visit:
GYNECOLOGICAL HISTORY |
Age of first period ______ Periods are ❒ regular ❒ irregular ❒ painful ❒ not bothersome
Age of last period ______ Menstrual flow is ❒ light ❒ moderate ❒ heavy ❒ very heavy
❒ Change tampon or pad every ______ hours
Usual cycle length ______ days, lasting ______ days
First day of last menstrual period ____/____/_____
Date of last pap smear ______/_____/______ ❒ normal ❒ abnormal findings ______________
Are you sexually active? ❒ yes ❒ no ❒ virginal
Method of Birth Control: ❒ condoms ❒ birth control pill ❒ patch ❒ vaginal ring ❒ tubal ligation / Essure® birth control ❒ IUD- intrauterine device
❒ natural family planning ❒ partner with vasectomy ❒ other
❒ I am considering pregnancy in the future. Please complete a Prenatal Questionnaire.
PREGNANCY HISTORY |
Total # Pregnancies ___ = Full Term ___ + Premature ___ + Miscarriages ___ + Abortions ___