Women's History
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In order to notify the clinic, please enter your name and other demographic information above and enter the name
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Provider Name
Patient Information
*
Please provide the patient's full legal name as it appears on their driver's license, state identification card, or government issued identification card.
Birth Month
January
February
March
April
May
June
July
August
September
October
November
December
Birth Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Year
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
Women's History
* Required Information
Social History
Caffeine
*
Drinks per day:
0
Occasionally
1-2
3-4
5-6
7 or more
*
Type(s) of caffeine:
Coffee
Tea
Soft drinks
Tobacco Use
*
How would you describe your cigarette smoking?
Current (every day)
Current (some days)
In the past
Never
*
How many packs per day do you smoke?
*
How many packs per day did you smoke?
Less than 1
1-2
More than 2
*
How many years have you smoked?
*
How many years did you smoke?
5 or less
6-10
More than 10
*
Do you use other tobacco products?
Currently
In the past
Never
Alcohol Use
*
Do you consume alcohol?
Currently
In the past
Never
*
Average number of drinks per week
(now or in the past)
?
7 or less
8-14
15 or more
Drug Use
*
Do you use street drugs?
Currently
In the past
Never
Prefer to discuss with physician
Abuse
*
History of physical abuse?
Yes
No
*
History of sexual abuse?
Yes
No
*
Occupation
Sexual Activity
*
Currently sexually active?
Yes
No
*
Total number of lifetime sexual partners?
None
Less than 10
More than 10
*
Planning a pregnancy this year?
Yes
No
Birth Control
*
Current birth control method?
IUD
Condom
Tubal sterilization
Abstinence
Pill
Rhythm
Hysterectomy
Other
Foam
Depo-provera®
Vasectomy
None
*
Monthly self breast exams?
Always
Frequently
Never
Exercise
*
Times per week:
0
Occasionally
1-2
3-4
5-6
7 or more
*
Type(s) of exercise:
Bicycling
Running
Swimming
Walking
Aerobics
Other
Seatbelt Use
*
How often do you wear a seatbelt?
Always
Almost always
Occasionally
Never
Diagnostic Testing / Wellness
*
Have you had an abnormal pap in the last 5 years?
N/A
Yes
No
*
Last pap smear?
None
Less than 1 year
1-5 years
More than 5 years
*
Last mammogram?
None
Less than 1 year
1-5 years
More than 5 years
*
Last DXA scan (bone density)?
None
Less than 1 year
1-5 years
More than 5 years
*
Last cholesterol level check?
None
Less than 1 year
1-5 years
More than 5 years
*
Last colonoscopy?
None
Less than 1 year
1-5 years
More than 5 years
*
Last sigmoidoscopy?
None
Less than 1 year
1-5 years
More than 5 years
*
Last fecal occult blood test?
None
Less than 1 year
1-5 years
More than 5 years
*
Last rubella immunity?
None
Less than 1 year
1-5 years
More than 5 years
Allergies
*
Please type your initials in the provided boxes for any of the following that apply.
No Known Allergies:
Latex:
Iodine / Shellfish:
Penicillin:
*
Your Medical History
Please indicate if
you
have a history of any of the following.
(Mark all that apply. if none, mark "
None
".)
History of taking antibiotics for dental work
Anemia
Gallbladder problems
Psychiatric problems
Anxiety disorder
GYN cancer (cervical, uterine, ovarian)
Rheumatic fever
Asthma
Heart disease
Sickle cell trait or disease
Blood clots
Heart murmur
Stomach / Bowel problems
Bleeding disorder
Stroke / CVA of the brain
Breast cancer
High blood pressure
Thyroid problems
Cancer
High cholesterol
Transfusion(s)
Chicken pox
HIV exposure
Varicose veins
Depression
Kidney problems
Other
Diabetes
Liver disease
Epilepsy / Seizures
PKU
None
*
Surgical History
Please indicate if
you
have had any of the following surgeries.
(Mark all that apply. if none, mark "
I have had no surgeries
".)
Bowel surgery
Rectal surgery
Colon surgery
Surgery on cervix
Abdominal hysterectomy
Incontinence surgery
Vaginal hysterectomy
Bladder surgery
Laparoscopies
Other
I have had no surgeries
*
Family Medical History
Please indicate if
your family
has a history of any of the following.
(Only include parent, grandparents, siblings, and children.)
Family history unknown
Adopted
Tuberculosis
Ovarian cancer
Sickle cell disease
Uterine / Endometrial cancer
Stroke
Colon cancer
Clotting disorder / hereditary disease
Cesarean section
Thyroid disease
Diabetes
High blood pressure
Other
Heart attack
Breast cancer
None
*
GYN History
Please indicate if
you
have a history of any of the following.
(Mark all that apply. If none, mark "
None
".)
DES exposure (mark if your mother took DES during pregnancy)
Tumors
Chlamydia
Severe pain during period
Bleeding between periods
Herpes
Cyst(s) of the ovary(ies)
Vaginal discharge
Genital warts
Infertility
Vaginal infection
HIV
Sexual difficulty
Syphilis
Abnormal pap smear(s
Pain / Bleeding during intercourse
Gonorrhea
Abnormality(ies) of the uterus
Bothersome loss of urine
Trichomonas
Severe cramping
Urinary problems
None
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 250
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