MEDICAL HISTORY 

Name: ________________________________________ DOB: ______________  
Reason for visit: _________________________________________
List of ALL medications INCLUDING DOSAGE and over the counter: _________________________________________________________________
_________________________________________________________________
_________________________________________________________________
HISTORY OF ALL MEDICAL CONDITIONS DIAGNOSED WITH: ______________________________________________________________
History of any psychological conditions: __________________________

Date of last: Annual Physical _____________ Bone Density ______________ 
Colonoscopy ___________ Glucose _________ Cholesterol _________
Dental exam___________ Eye exam ____________ 

Immunizations/Vaccines: Tetanus _____________ Flu ____________ Pneumonia _________ Shingles ________
Hepatitis A _______ Hepatitis B __________ HPV(Gardasil) _________ Meningitis _________

ALLERGIES TO MEDICATIONS___________________________________________

First day of last period: ______ Age at first period: ________
How is your menstrual flow: Light________ Moderate_______ Heavy_____ How many days________
Cramps with cycle: Yes, _____ No_____   Do you have PMS: Yes, ______ No _____
Bleeding between cycles: Yes, ____ No ____ Bleeding with intercourse: Yes, _____ No_____
Birth control name: _______________________
History of STD: Yes, _________ No _____________ 
Date of last pap smear: _______________ Results: ___________________
History of abnormal pap: Yes, ______ When: _____ Result: ________ No_______

Mammogram ___________Problems with breast: Yes, __________ No_______ 
Hysterectomy: ________ When: ________
Problems with urination Yes, _____ No _______ 
Vaginal discharge: Yes, _____ No _____
Number of Pregnancies ______________ C-section __________

Surgeries: _____________________________________________________
Hospitalizations: ___________________________________________________

Family History: Breast cancer________ Uterine cancer________ Ovarian cancer______
Colon cancer _____ Diabetes______ Heart disease ____ High blood pressure______
Stroke ____ Thyroid disease ______ Autoimmune _______ Osteoporosis______
Other family history _________________________________________________________

Smoker: Yes, ______ No ________ Past smoker when did you stop ______________
Alcohol: Yes, ______ How often: ________ No _______ Social drugs: Yes, ______ No _______

Do you have an advanced directive: Yes, _____ No __________