New Gyn Patient

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Medical History (Please select all that apply)
Alcoholism		Cancer (If yes, what kind?)		Genetic Condition		Mitral Valve Prolapse
Anemia		Chicken Pox		Heart Attack		Osteoarthritis
Anxiety		Depression		Heart Disease		Pelvic Infections
Asthma		Diabetes Type I		High Blood Pressure		Pneumonia
Autoimmune Disease		Diabetes Type II		High Cholesterol		Rheumatoid Arthritis
Bladder Infections		Drug Dependence		Hyperthyroidism		Seizures
Bleeding Problems		Eating Disorders		Hypothyroidism		Sickle Cell Anemia
Blood Clot in Legs		Epilepsy		Kidney Infection		Stroke
Blood Clot in Lungs		Esophageal Reflux		Liver Disease		Tuberculosis
Blood Transfusions		Gallbladder Disease		Migraine

Have you ever had any of the following STDs?
Chlamydia		Gonorrhea		Hepatitis B/Hepatitis C		Herpes
HIV		HPV		Syphilis		Trichomoniasis

	Date	Results			If abnormal, please specify
Last Blood Work		Normal	Abnormal
Last Bone Density		Normal	Osteopenia Osteoporosis	Never had one
Last Colonoscopy		Normal	Abnormal	Never had one
Last Mammogram		Normal	Abnormal	Never had one
Last PAP Smear		Normal	Abnormal	Never had one

Have you ever needed any of the following for an abnormal PAP Smear? (Select all that apply)
Colposcopy		Cryosurgery		LEEP/Laser conization		None

Have you ever had any of the following?
Endometriosis		Fibrocystic breasts		Ovarian Cyst		Uterine fibroids

Family History Please list any close relatives with history of the following
Condition	Relative	Side of Family	Age at Diagnosis	Notes
Breast Cancer		Mother Father Unknown
Colon Cancer		Mother Father Unknown
Diabetes Type 1		Mother Father Unknown
Diabetes Type 2		Mother Father Unknown
Heart Disease		Mother Father Unknown
High Blood Pressure		Mother Father Unknown
Ovarian Cancer		Mother Father Unknown
Stroke		Mother Father Unknown
Uterine Cancer		Mother Father Unknown

Obstetrical History
Have you ever been pregnant?	Yes	No
Have you adopted children?	Yes	No

Pregnancy History
Name	Age	Date	Length of Pregnancy	Birth Weight	M/F	Type of Delivery	Anesthesia	Early Labor?	Complications?
					M F			Y N	Y N
					M F			Y N	Y N
					M F			Y N	Y N
					M F			Y N	Y N

Gynecological History
First Day of Last Menstrual Period
How long did it last?
Flow?	Regular	Moderate	Heavy
Periods are?	Regular	Irregular	Painful	Light
Method of birth control?	Condoms	Pills	Depo	IUD
	Vaginal Ring	Tube Ligation	Partner with Vasectomy	Natural Family Planning
	Other

Social History
Occupation
Marital Status	Single	Married	Separated	Divorced	Widowed
Alcohol Use	Yes	No
Tobacco Use	Yes	No
Recreational Drug Use	Yes	No
Exercise	Yes	No
Caffeine	Yes	No
Sexual Abuse	Yes	No
	Are you safe now?	Yes	No	Need Counselling?	Yes	No
Physical Abuse	Yes	No
	Are you safe now?	Yes	No	Need Counselling?	Yes	No
Emotional Abuse	Yes	No
	Are you safe now?	Yes	No	Need Counselling?	Yes	No

Review of Systems
Constitutional	Fever	Fatigue
Eyes	Double Vision	Spots Before Eyes
Ear, Nose and Throat	Earaches	Sore Throat
Breasts	Nipple Discharge	Lumps
Cardiovascular	Chest Pain or Pressure	Rapid or Irregular Heartbeat
Respiratory	Shortness of Breath	Chronic Cough
Gastrointestinal	Frequent Diarrhea	Constipation
Genitourinary	Blood in Urine	Pain with Urination	Involuntary Urine Loss	Abnormal Bleeding
	Painful Periods	Premenstrual Syndrome (PMS)	Abnormal Vaginal Discharge	Painful Intercourse
Skin	Rash	Moles (Growth/Changes)
Neurologic	Dizziness	Frequent Headaches
Musculoskeletal	Muscle Weakness	Muscle or Joint Pain
Endocrine	Hair Loss	Hot Flashes
Psychiatric	Depression or Frequent Crying	Anxiety
Hematologic/Lymphatic	Frequent Bruising	Enlarged Lymph Nodes (Glands)

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Acknowledgment
Patient/Responsible Party
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