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MEDICAL HISTORY FORM
Patient Health History Form
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First name
Last name
Middle name
Date of Birth
Email address
Mobile Phone number
Reason for upcoming visit
Preferred pharmacy?
Who is your Primary Care Provider?
Do you have any drug allergies
Yes
No
If yes, what is your reaction?
Please list current medication you are taking, to include over-the-counter medications and vitamins
When was you last Flu shot?
When was your last COVID vaccine?
When was you last Tdap?
Please list any current medical problems you are being treated for
When was your last pap smear?
Do you have a history of abnormal paps?
Yes
No
If yes, what was the result?
First day of your last period.
Duration of your flow?
What is the frequency of your cycle?
How would you describe your flow?
At what age did you first get your period?
Are you sexually active?
Yes
No
Are you experiencing any sexual problems?
Have you ever been diagnoses with an STD/STI?
What is your current birth control method?
Have you completed the HPV vaccine series?
Yes, all
Yes, in-progress
No
Have you been diagnosed with PCOS?
Yes
No
Have you been diagnosed with Endometriosis?
Yes
No
Have you been diagnosed or treated for infertility?
Yes
No
When was your last mammogram?
When was your last bone density scan?
Are you currently on hormone replacement therapy?
Yes
No
Are you currently experiencing any urinary issues?
How many total times have you been pregnant?
Out of your total pregnancies, how many were full-term deliveries (38+wks)?
Out of your total pregnancies, how many were premature deliveries?
How many ended in miscarriage?
How many ended in an ectopic pregnancy?
How many ended with elective termination/ abortion?
How many children are still living today?
Do you have any family members with the following cancers?
Breast Cancer
Ovarian Cancer
Uterine/Endometrial Cancer
Prostate Cancer
Colon Cancer
Melanoma
Other
Of yes above, please list which cancer and what relation.
Please list any other medical condition and which family members.
Is your mother still living?
Is you father still living?
What is the highest grade of school you completed?
Are you currently employed?
What is your occupation?
What is your relationship status?
Have there been any changes to your family or social situation?
Do you or have you ever smoked tobacco?
No - never
Yes - former
Yes - current
If yes, how much do you smoke?
When did you stop smoking?
Do you or have you used any other form of tobacco or nicotine?
No - never
Yes - former
Yes - current
Do you or have you use e-cigarettes or vape?
No - never
Yes - former
Yes -current
Do you or have you used smokeless tobacco?
No - never
Yes - former
Yes - current
What is your level of alcohol consumption?
Do you or have you used illicit or recreational drugs?
No - never
Yes - former
Yes - current
What type of diet are you following?
What is your exercise level?
What is your sexual orientation
Gender identity
Pronouns
Would you like for us to use a different first name?
Please list all surgical procedures and approximate dates:
Do you now have, or have you ever had:
Domestic violence/abuse
Acid reflux
Anemia
Anesthesia complications
Arthritis
Birth defects of inherited disease
Blood transfusion
Breast problems
Cancer
Diabetes
GI problems
Headache / migraine
Heart disease (attack, valve replacement, A-Fib)
Hepatitis
High cholesterol / lipids
Hypertension
Kidney disease
Lung disease (asthma, OCPD)
MRSA
Neurological disorders
Osteoporosis
Other
Mental health issues (anxiety, depression)
Stroke
Thrombophilias
Thyroid problems
Varicosities
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