Past Medical, Family & Social History

Past Medical History	Patient	Family	Denied
1. A thyroid problem
2. A heart condition or high blood pressure
3. A lung disorder
4. Tuberculosis
5. Jaundice, hepatitis, or other liver disorders
6. Stomach, bowel or gallbladder problems
7. Kidney or bladder problems
8. Female or sexual problems
9. Hemophilia / Sicklecell Anemia
10. A blood transfusion
11. Diabetes
12. Cancer
Ovarian
Uterine
Breast
13. Birth Defects or inherited diseases
14. Other medical problems

Obstetrical History   Please list the number of:

Times pregnant		Premature births		Mis-carriages
Abortions		Living Children

No.	Born month/year	Weight at birth	Baby's sex	Weeks preg.	Type of delivery	Complications
						Yes	No
1
2
3
4

Past Surgical History & Hospitalizations (Check box if more than four)
Month/Year	Illness or operation	Complications
		Yes	No

Menstrual History
Date of Last Period		Frequency		Days
Length
Age of First Period
Abnormal bleeding
Pain

Family Planning
	Past	Present
Oral contraceptive
IUD
Diaphragm
Other:
Sterilization:    Male          Female
Infertility:    Yes          No
Duration:

Review of Systems
Do you now or have you had any problems related to the following systems? Check Yes or No
Please explain any Yes answer in the space provided

Constitutional Systems	Yes	No
Fever
Chills
Headaches
Anorexia
Endocrine	Yes	No
Excessive Thirst
Too hot/cold
Tired/sluggish
Night Sweats
Weight loss
Gastrointestinal	Yes	No
Abdominal Pain
Nausea/vomiting
Indigestion/heartburn
Constipation
Cardiovascular	Yes	No
Stroke
Thrombosis (Clots in Veins)
High Blood Pressure
Integumentary	Yes	No
Skin rash
Boils
Persistant itch
Musculoskeletal	Yes	No
Joint pain
Neck pain
Back pain
Genitourinary	Yes	No
Leakage of Urine
Painful urination
Urinary frequency
Respiratory	Yes	No
Wheezing
Frequent Cough
Shortness of breath
Bloddy Sputum
Hematologic/Lymphatic	Yes	No
Swollen glands
Blood clotting problem
Psychologic	Yes	No
Are you generally satisfied with your life?
Do you feel severely depressed?
Have you considered suicide?
	Yes	No
Seizure Disorder

Medicare "High Risk" Criteria Have you ever been treated for any of the following infections? Vaginosis Genital Warts Chlamydia Herpes Trichomonas Gonorrhea Syphilis Have you had a Pap smear in the last 7 years? No Yes Have you ever had an abnormal Pap smear test? No Yes   When Did you begin sexual activity before you were 16 years old? No Yes Have you had more than 5 sexual partners in your lifetime? No Yes Have you ever tested positive for the HIV virus? No Yes Did your mother take the drug DES when she was pregnant with you? No Yes

Date	Patient Signature