•~~NorthEast Women's Health & Obstetrics

o Concordo Renaissance

PATIENT HISTORY FORMDate: Name you wish to be called: _

Name: ~~-------------~~---------~~----------First Middle Last

Address: __ ~-----------------------------------------Street

City State Zip Code Email

Home Phone: Work Phone:. Cell Phone: _

Date of Birth: Age: Race: _

Present Illness (describe in detail your problem or reason for today's visit):

Obstetric

Number of pregnancies: _

Allergies and reaction: _

Number of Miscarriages: _ Number of Births: _

Current Medications Dosage Prescribing MD When did you start med?

Pharmacy: Birth Control Method: _

Past surgeries and dateofsurge~: _

Past illnesses and medical problems: ~

Social HistoryDo you smoke? Yes No Are you (circle one):

How much per day? Single Married Widowed SeparatedDo you drink alcohol? Yes No If married, how long? _

# of drinks per week? Are sexual relations satisfactory?Do you have a history of Do you feel safe where you live?substance or drug abuse? Yes No In the past year, have you beenWhat is your occupation?_____________ Threatened, hit, slapped, or kickedWhat is your religion? by anyone you know?

Yes NoYes No

Yes No

Family History-check any illnesses in yourfamily & which family member diagnosed: Mother Father Sister BrotherHeart diseaseCancer (and tvoe)Hiah Blood PressureThvroid diseaseDiabetesResoiratorv oroblemsAny other problems you think we should be aware of:

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Gynecological/UrologicalDate of last menstrual period (LMP), _Period prior to LMP _Age you started menstruation _How often do you menstruate? Every daysHow long do your periods last? daysIf you have cramps, are they:

Mild ModerateAre your periods regular?When was your last pap?Have you ever had an abnormal pap?

Are you experiencing any of the following?Pain with intercourse YesSpotting between periods YesBleeding/spotting after intercourse YesFrequent urination YesLeaking urine when you cough

sneeze or laugh YesVaginal pressure or feeling that

something is "falling out" YesPain with urination? YesBlood in urine? Yes

(circle one)Severe No Cramps

Yes No

Yes No

Endocrine LungsAbnormal hair growth? Yes No Any shortness of breath? Yes NoProblems with acne? Yes No Do you have a cough? Yes NoSevere hot flashes/night sweats? Yes NoDate of last bone density? Heart

Have you experienced any of the following?Constitutional Chest Pain Yes No

Have you had fevers? Yes No Palpitations Yes NoDo you have unexplained weightloss or weight gain? Yes No Extremities

Do you have any numbness? Yes NoSkin Do you have any swelling in your legs? Yes NoDo you have any abnormal skin lesions? Yes No

MusculoskeletalGastrointestinal Do you have any joint pain? Yes NoAre you experiencing any of the following?

Constipation Yes No Central Nervous SystemDiarrhea Yes No Do you have any of the following?Rectal Bleeding Yes No History of seizures Yes NoHemorrhoids Yes No Severe headaches Yes No

Any recent change in bowel habits? Yes No Vision problems Yes NoDate of last colon screening? Weakness Yes No

Do you wear glasses or contacts? Yes NoBreastsDo you have these symptoms in either breast or underarm? Psychiatric

Lumps Yes No Are you bothered with depression, anxiety,Discharge Yes No or mood instability? Yes NoPain Yes No

Date of last mammogram?

Patient Signature: _

NoNoNoNo

No

NoNoNo

For Office Use Only=============================================================================================================================================

Reviewed by:Provider's Signature

BPHtWtTemp _BMIPain rating

LabsUAHgbUPTHernoccult _Wet Mount ----

PregnancyLMPGAEDC _

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