Patient Medical History Patient Medical History Patient Name * Date of Birth * Email * Primary Care Physician (Required if Medicare Patient) Pharmacy Name Pharmacy Location Are you allergic to latex? * Yes No Allergies Family History Diseases Diabetes Heart Disease Hypertension Cancer Mother Diabetes Heart Disease Hypertension Cancer Father Diabetes Heart Disease Hypertension Cancer Brother Diabetes Heart Disease Hypertension Cancer Sister Diabetes Heart Disease Hypertension Cancer Maternal Grandmother Diabetes Heart Disease Hypertension Cancer Maternal Grandfather Diabetes Heart Disease Hypertension Cancer Paternal Grandmother Diabetes Heart Disease Hypertension Cancer Paternal Grandfather Diabetes Heart Disease Hypertension Cancer Maternal Aunt Diabetes Heart Disease Hypertension Cancer Maternal Uncle Diabetes Heart Disease Hypertension Cancer Paternal Aunt Diabetes Heart Disease Hypertension Cancer Paternal Uncle Diabetes Heart Disease Hypertension Cancer * Please list what type of cancer for any family members indicated: Any family history of Birth Defects? * Yes No Please list Any family history of Twins? * Yes No Which side? Maternal side of family Paternal side of family Section Buttons Social History Illegal Drug Use? * Yes No What drug(s) 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 Hysterectomy Partial Complete Other Section Buttons Medications Medications (Name/MG/Dosage) Prenatal vitamins * Yes No Section Buttons 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 Section Buttons 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 End Section Past Pregnancies Date of Delivery OR Date of Miscarriage or Termination Length of labor (hours) Delivery Type Vaginal C-Section Anesthesia 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) Gender Boy Girl End Section Submit
