Medical History

Today's Date:
Name: *
Address:
Occupation:
Age:
Birth date:
Sex M/F:		Male Female
Home Phone:
Work Phone:
Email address: *

Emergency Contact

Please choose one:		Married Single Divorced Widowed Separated
If married, spouse's name:
Children's name and ages:
Allergies to medications, X ray, dyes, or other substances:		Yes No	If yes, please list name of medicines and type of reaction:

Past Medical History & Review of Systems

Please check all that apply if you have had problems with or are presently complaining of any of the following.

High Blood Pressure	Bronchitis	Change in bowel habits	Arthritis
Diabetes	Pneumonia	Weight changes	Low back problem
Cancer	Persistent cough	Hemorrhoids	Skin diseases
Heart Disease	Hay Fever	Gall Bladder	Blood disorders
Chest pain / tightness	Abdominal discomfort	Colitis	Venereal diseases
Shortness of breath	Indigestion	Hepatitis / Jaundice	Anxiety
Swollen ankles	Nausea	Thyroid disease	Depression
Palpitations	Vomiting	Head / Neck radiation	Anemia
Lightheadedness	Constipation	Headaches	Alcohol abuse
Frequent urination	Diarrhea	Kidney disease	Drug abuse
Rheumatic fever	Blood in stool	Kidney stones	Gout
Asthma	TB	Difficulty urinating	Ulcer

Other:
Other:
List present health problems and concerns:

Gynecologic and Obstetric History

Age at onset of periods:		Frequency:		Length of period:
Pregnancies:		Births:		Miscarriages:

Prolonged or abnormal bleeding:		Choose one Yes No Please Describe
Leakage of urine:		Choose one Yes No Please Describe
Pelvic pain:		Choose one Yes No Please Describe
Abnormal discharge:		Choose one Yes No Please Describe
History of abnormal Pap smear:		Choose one Yes No Please Describe