Health History - Adult Female - Circle of Life Family Medicine

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Health History - Adult Female

Please fill in all relevant information.

* NOTE * You must expand each section to fill out the information

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Date of Appointment

Patient's First Name

Patient's Last name

Patient Date of Birth (Must be MM/DD/YYYY format, including the forward slash)

Phone number (Must be XXX-XXX-XXXX format, including dashes)

Personal Information (+ click to expand)

Last appointment with primary care physician? (If unsure, give estimate)

How did you hear about our practice?

What would you like to address today?

What is your current occupation?

Who do you live with?

Do you have children?YesNo

Child(ren) name(s) and age(s)

Do pets live in the house?YesNo

Pet type(s)

Have you traveled out of the country in the past 6 months?YesNo

Locations

Lifestyle/Risk Assessment (+ click to expand)

Smoking, alcohol, drugs, abuse

Do you currently smoke cigarettes?YesNo, NeverQuit

Date Started and Amount of packs/day

Date Stopped

Do you currently/have you ever had exposure to second hand smoke?YesNo

How many alcoholic drinks do you have in an average week?

Do you ever drink more than 3 at one sitting?YesNo

What recreational drugs are you currently using?NoneMarijuanaHeroinCrackCocainePain killersOther

Other type

Have you ever used recreational drugs in the past?YesNo

How often?

Types of drugs

Have you been physically or emotionally abused or a victim of domestic violence?YesNo

Do you feel safe now?YesNo

Exercise & Diet (+ click to expand)

exercise and diet

Do you exercise and if so, how often?regularlyoccasionallyrarelynever

Do you currently have any concerns about your weight?nonegainloss

What type of exercise?

Do you have any concerns about what you eat?noyes

How many different types of fruits/vegetables do you have in your house right now?0-34-89 or more

Gynecologic History (+ click to expand)

GYNECOLOGIC HISTORY (Please check all that are relevant)

Chronic pelvic pain

DES Exposure in utero (when your mother was pregnant with you)

Pain with sex (dyspareunia)

Endometriosis or Adenomyosis

Fibroids, uterine

Infertility

Ovarian cyst

Ovarian cyst type

PMS

Abnormal Uterine Structure (Uterine Anomaly)

Urinary Incontinence

Vaginal dysplasia (precancer)

Vulvar dysplasia (precancer)

Vulvar Pain/Vulvodynia

Recurrent Vaginitis

Yeast

Pelvic Inflammatory Disease

STI/Sexually Transmitted InfectionsChlamydiaGenital HerpesGonorrheaGenital WartsHepatitis BHepatitis CHIV/AIDSSyphilis

Other

None of the above

Other (specify)

Sexual History (+ click to expand)

SEXUAL HISTORY

Are you currently sexually active?YesNo

Are your partner(s)?malefemalebothnone

Do your or your partner have more than one partner?yesno

Do you have concerns about sexually transmitted infections?yesnounsure

Do you want to be screened for HIV, the virus that causes AIDS?yesnounsure

Do you have any concerns about sex?yesno

Menstrual Information (+ click to expand)

If pre-menopausal (still menstruating):

When was your last menstrual cycle (if unsure, estimate date)?

Do you have concerns about your menstrual cycle?yesno

Are your periods currently:regularirregular

Is your flow:lightmoderateheavy

How many days do your periods last?

How often do you have periods?

Do you have spotting or bleeding between periods?yesno

Do you have menstrual pain/cramping?nomildmoderatesevere

What medications do you take for this?

If post-menopausal (no longer menstruating):

Are you experiencing any vaginal bleeding?yesno

Did you use hormones?yesno

If yes, vaginalcurrentpast

If yes, systemiccurrentpast

Preventative Information (+ click to expand)

PREVENTATIVE CARE

Date of last physical exam (if unsure, estimate date)

Do you wear sunscreen?YesNoSometimes

Do you wear a seatbelt?YesNo

Date of last colonoscopy (if unsure or n/a, state accordingly)

Date of last pap smear (if unsure, estimate date)

Where was your last PAP smear performed?

Have you ever had an abnormal pap smear?yesno

Date

Date of last mammogram

Place of last mammogram

Do you take calcium supplements?yesno

What method of birth control, if any, are you using?

Are you planning a pregnancy in the next year?yesno

Allergies (+ click to expand)

Are you allergic to IVP dye, shellfish or Latex?yesno

Do you have any allergies/reactions to medications or other agents?yesno

Allergen and reaction

Are you taking any medications/supplements/vitamins?yesno

Medication Name/Dose/Frequency

Have you obtained a Tdap immunization (tetanus, diphtheria, pertussis)?yesnounsure

Have you been vaccinated against the HPV virus?yesnounsure

Immunizations (+ click to expand)

Have you had a flu shot this year?yesnounsure

Medical/Family History (+ click to expand)

MEDICAL/SURGICAL HISTORY

Since your last exam here, have you had any major health problems?yesno

Explain

Please list any past surgeries/hospitalizations (surgery type/reason/place/date) (if none, type "none")

FAMILY HISTORY
Please check if there is a family history of any medical problems below (mother, father, siblings, grandparents, aunts, uncles, cousins) for both maternal (mother's) or paternal (father's) side.

Please type family member next to problem, i.e. mother, father, etc., and use (M) for maternal and (P) for paternal.

Check here if Family History is unknown

ADD

Alcohol Abuse

Allergy

Aneurysm

Asthma

Birth Defects

Cancer (other than skin)

Cholesterol (high)

Development

Diabetes

Drug Abuse

Eczema

Heart Disease

High Blood Pressure

Kidney

Mental Illness

Mood disorder

Obesity

School Problems

Seizures

Skin Cancer

Stomach/Bowel

Stroke

Substance abuse

Thyroid

Any other medical condition that runs in the family

Review of Systems (+ click to expand)

Check if you CURRENTLY have problems with any of the following (by submitting this form, you are stating that anything left blank is answered in the negative):

fatigue

fever

weight loss

weight gain

easy bruising

enlarged glands or lumps

environmental allergies

hot flashes

heat or cold intolerance

excessive hair growth

excessive hair loss

skin

moles

chest pain

seizures

palpitations

excessive thirst

irregular periods

missed periods

runny nose

waking at night 3x to urinate

persistent cough

shortness of breath

wheezing

difficulty breathing

indigestion or nausea

abdominal pain

abdominal bloating

constipation

diarrhea

involuntary loss of urine

painful urination

abnormal vaginal discharge

headaches

leg swelling

frequent urination

kidney stones

pelvic pain

sinus pain

pregnancy/infertility

seasonal allergies

fainting/dizziness/balance

anxiety

depression

memory loss

trouble sleeping

varicose veins

muscle or joint pain

back pain

breast pain

breast discharge

breast lump

visual changes

numbness

jaw pain

blood in stool/rectal bleeding

blood in urine

sore throat

ear pain

ringing in ears

eye pain

other

Verification Text