Medical History Update Download Form Patient Name (Required) Date of Birth (Required) Email Address (Required) Reason for today's visit —Please choose an option—AnnualFollow-UpProblemOther Brief description of problem or other concern Personal Health History When was the first day of your last menstrual period? Was your last period normal? —Please choose an option—YesNo How frequently does your period occur? How many days does your period last? Do you experience irregular or inconsistent bleeding patterns? —Please choose an option—YesNoSometimes Current method of birth control? Would you like information on a simple, safe procedure performed in our office that can reduce or eliminate your monthly periods? —Please choose an option—YesNo Is your family complete? —Please choose an option—YesNo Would you like information on a gentle hormone free permanent procedure? —Please choose an option—YesNo Do you have any problems/concerns with leaking urine, frequency or painful urination? —Please choose an option—YesNo Please check all that apply to yourself: Breast CancerUterine CancerColon CancerOvarian CancerCervical CancerOther CancerThyroid IssuesDiabetesHigh Blood PressureHigh CholesterolAbnormal Pap SmearTreatment of Abnormal Pap Any other cancers or diseases not mentioned Please list All Surgeries Social History Occupation Marital Status Is violence at home a concern for you? —Please choose an option—YesNo Have you ever been abused? —Please choose an option—YesNo Do you use tobacco? —Please choose an option—YesNo If yes, how many packs per day? Do you drink alcohol? —Please choose an option—YesNo If yes how many drinks per week? Do you use drugs? —Please choose an option—YesNo If yes, what type? Are you sexually active? —Please choose an option—YesNoNot currentlyHave Never been sexually active Have you had four or more sexual partners? —Please choose an option—YesNo Have you had any sexually transmitted diseases? —Please choose an option—YesNo Have you had a weight change in the last year? —Please choose an option—YesNo If yes —Please choose an option—GainLoss How many pounds? Do you exercise 3 or more times a week? —Please choose an option—YesNo Please List Current Medications and Herbal Supplements Please List Allergies: (Medication and Food) Review of Symptoms Please check any current problems you have on the list below General ChillsFeverFatigueWeight LossNo Problem Skin RashSweatyItchyAcneNo Problem Gastrointestinal Abdominal PainConstipationDiarrheaNauseaVomitingNo Problem Neurological SeizuresDizzinessSyncopeWeaknessNumbnessNo Problem Hematology Easy BleedingEasy BruisingNo Problem Ear/Nose/Throat Hearing LossNosebleedsSore ThroatRhinitisNo Problem Endocrine Heat/Cold IntoleranceExcessive ThirstNo Problem Cardiac Chest PainPalpitationNo Problem Psychiatric DepressionAnxietyNo Problem Respiratory CoughShortness of BreathNo Problem EyesBlurred VisionLight SensitivityNo Problem Urinary Painful UrinationDischargeBloody UrineIncontinenceFlank PainWeak StreamIncomplete VoidingFrequent UrinationStrainingHesitancyUrgencyNo Problem Please check any symptoms you are experiencing and the frequency or severity of the symptoms Night Sweats —Please choose an option—Never1-3 Times/WeekNightly Sleeping Problems —Please choose an option—Never1-3 Times/WeekNightly Hot Flushes —Please choose an option—Never1-3 Times/WeekNightly Sexual Desire —Please choose an option—Not a ProblemDecreasedNo Desire Pain with Intercourse —Please choose an option—NeverOccasionallyAlmost Always Vaginal Dryness —Please choose an option—NeverOccasionallyAlways Urine Leakage —Please choose an option—NeverOccasionallyAlmost Always Difficulty Concentrating —Please choose an option—Not a ProblemGetting WorseAlmost Always Memory Loss —Please choose an option—Not a ProblemGetting WorseAlmost Always Foggy Thinking —Please choose an option—Not a ProblemGetting WorseAlmost Always Mood Swings —Please choose an option—RarelyOccasionallyFrequently Depression —Please choose an option—RarelyOccasionallyFrequently Anxiety —Please choose an option—RarelyOccasionallyFrequently Headaches—Please choose an option—Never1-3 Times/WeekWeekly Muscle Pain —Please choose an option—Never1-3 Times/WeekWeekly Joint Pain —Please choose an option—Never1-3 Times/WeekWeekly Breast Pain/Lump —Please choose an option—Never1-3 Times/WeekWeekly Are you taking medication or herbal supplements for any of the above symptoms? —Please choose an option—YesNo
