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Patient History Form
Patient Name
Date of Birth
Primary Care Physician
(Required if Medicare Patient)
Pharmacy Name
Pharmacy Location
Are you allergic to latex?
Yes
No
Allergies
Family History
Diabetes
Heart Disease
Hypertension
(high blood pressure)
Cancer *
Mother
Father
Brother
Sister
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
* Please list what type cancer for any family members indicated:
Any family history of Birth Defects?
Yes
No
If yes, please list
Any family history of Twins:
(patient only, do not include spouse history)
Yes
No
If yes,
maternal side of family
paternal side of family
Social History
Illegal Drug Use?
Yes
No
If yes, what drug and last time used?
Cigarette Smoker?
Yes
No
How many per day?
Former smoker?
Yes
No
Caffeine
Coffee
Tea
Soda
N/A
Alcohol Use?
Yes
No
Sexuality/Contraception
NONE - patient is pregnant or trying to conceive
Abstinence
Oral Contraceptives (Birth control pills)
Depa-Provera injection
NuvaRing
Condoms
Withdraw
Vasectomy
IUD: Mirena or Paragard or Other
Tubal ligation
Hysterectomy
Partial
Complete
Medications
Medications (Name/MG/Dosage)
Prenatal vitamins
Yes
No
Pregnancy Information
Gravida
(total number of pregnancies)
Para
(total number of births)
MAB
(total number of miscarriages)
VIP
(total number of terminated pregnancies)
LMP
(first day of last menstrual cycle)
Past Surgeries
Diagnostic Studies
Date of last Pap Smear
Results
Date of last Mammogram
Results
Date of last Dexa Scan/Bone Density
Results
Please note any history of abnormal Paps, Colpo, Cryo, LEEP
Current Medical Conditions/Illnesses
Past Pregnancies
Date of Delivery
OR
Date of Miscarriage or Termination
Length of labor (hours)
Vaginal
C-Section
Natural
Epidural
Spinal
Pregnancy Complication(s)
Place of delivery / Physician
Delivery Complication(s)
Number of weeks gestation at delivery
Baby's birth weight at delivery (lbs)
Boy
Girl
Add pregnancy