MEDICAL HISTORY

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Name Date
Home Phone Work Phone
       
Date of Birth /  /   Age
SS#    
       
Reason for Visit?
   
Allergies
 
Last Menstrual Period /  /  
How long does your period last? days
Usual interval between periods is days
 
Please describe any changes in your menstrual pattern:
 
 
       
Since your last visit have you developed:
 
Pain with your periods
Severe PMS symptoms
Abnormal discharge
Menopausal symptoms
   
Pap Test   Mammogram  
Date of Last Test /  /   Date of Last Test /  /  
Result
Normal
Abnormal
Result
Normal

Abnormal
       
Contraceptive History    
     
Current Method Past Method
If Pill, Brand    
       

Past Medical & Family History

Please check if you (P = personal) or any blood relative (F = family) had any of the following conditions.
             
  P  F   P  F Physician's Notes
Weight Loss / Gain   Blood Transfusions    
Headaches / Migraine   Anemia / Blood Disorder    
Heart Disease
(Valvular or Rheumatic)		 Varicose Veins / Phlebitis    
Hypertension Skin Disease  
Respiratory Disease Diabetes  
Breast Disease Night Sweats  
Tuberculosis Thyroid Disease  
Jaundice / Hepatitis Cancer (Type)  
Gall Bladder Disease    Breast  
H. Hernia / Peptic Ulcer    Colon  
Bowel Disorders    Ovarian  
Kidney Disease Epilepsy / Neurological Disorders  
Urinary Incontinence Arthritis  
Urinary Infections        
       
Previous Surgery
(Example: Hysterectomy)
   
Current Medications
(list dosage and frequency)
       
Do you smoke cigarettes? Yes No If so, how many cigarettes per day?   
Do you drink? Yes No If so, how many per day?    
       
Do you use street drugs? Yes No    
     If so, please describe
       
Are you sexually active Yes No    
     If so, any problems?
       
Are you interested in obtaining more information about the following health issues? (please check)
   
 
Mammography Estrogen Replacement Therapy
Contraception Quitting Smoking
Nutrition Exercise
Domestic Violence / Personal Safety at Home
       
       

Obstetrical History
Number of times pregnant Premature babies
Miscarriages Abortions
Living Children    
       
  Born
Yr / Mo		 Weeks
Pregnant		 Weight Sex Type of Delivery Remarks
1 /
2 /
3 /
4 /
5 /
6 /

 
David B. Schwartz M.D. | Contact Us
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