Medical History Update Download Form Patient Name (Required) Date of Birth (Required) Email Address (Required) Reason for today's visit ---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? ---YesNo How frequently does your period occur? How many days does your period last? Do you experience irregular or inconsistent bleeding patterns? ---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? ---YesNo Is your family complete? ---YesNo Would you like information on a gentle hormone free permanent procedure? ---YesNo Do you have any problems/concerns with leaking urine, frequency or painful urination? ---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? ---YesNo Have you ever been abused? ---YesNo Do you use tobacco? ---YesNo If yes, how many packs per day? Do you drink alcohol? ---YesNo If yes how many drinks per week? Do you use drugs? ---YesNo If yes, what type? Are you sexually active? ---YesNoNot currentlyHave Never been sexually active Have you had four or more sexual partners? ---YesNo Have you had any sexually transmitted diseases? ---YesNo Have you had a weight change in the last year? ---YesNo If yes ---GainLoss How many pounds? Do you exercise 3 or more times a week? ---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 ---Never1-3 Times/WeekNightly Sleeping Problems ---Never1-3 Times/WeekNightly Hot Flushes ---Never1-3 Times/WeekNightly Sexual Desire ---Not a ProblemDecreasedNo Desire Pain with Intercourse ---NeverOccasionallyAlmost Always Vaginal Dryness ---NeverOccasionallyAlways Urine Leakage ---NeverOccasionallyAlmost Always Difficulty Concentrating ---Not a ProblemGetting WorseAlmost Always Memory Loss ---Not a ProblemGetting WorseAlmost Always Foggy Thinking ---Not a ProblemGetting WorseAlmost Always Mood Swings ---RarelyOccasionallyFrequently Depression ---RarelyOccasionallyFrequently Anxiety ---RarelyOccasionallyFrequently Headaches---Never1-3 Times/WeekWeekly Muscle Pain ---Never1-3 Times/WeekWeekly Joint Pain ---Never1-3 Times/WeekWeekly Breast Pain/Lump ---Never1-3 Times/WeekWeekly Are you taking medication or herbal supplements for any of the above symptoms? ---YesNo
