Female Patient Form - Glendale AZ

REPRODUCTIVE HEALTH CENTER
FEMALE PATIENT HISTORY
I. Identifying Information

       
II. Medical History
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo

1. 2.
3. 4.
5. 6.
YesNo

1. 2.
3. 4.
5. 6.
NoneAnemiaAnorexiaAppendicitisArthritisAsthmaBladder InfectionsBlood TransfusionsBreast Milky DischargeBreast SorenessBreast TendernessChest PainChlamydiaChronic BronchitisChronic HeadachesColitisColor BlindDiabetesDizzinessEndometriosisEpilepsyGallbladder ProblemsGonorrheaHeart DiseaseHepatitis Type?HerpesHirsutism (Excess Hair Growth)Rheumatic FeverHigh Blood PressureImmunization:German MeasleKidney InfectionLiver ProblemsLoss of BalanceLupusMeasles:GermanMeasles:RegularNeurological ProblemsNongonococcal UrethritisOvarian CystsParasitic InfectionPelvic InfectionPneumoniaPoor Sense of SmellProblems with Skin PigmentationScarlet FeverSeizuresSpastic ColonSyphilisTuberculosisUlcersVaginitis: Trichomoniasis Yeast, # of episodes:Visual DisturbancesVitiligoThyroid Problems?

   

N/AAlcohol - How many glasses per week do you usually drink? Wine Beer CocktailCigarettes - Number of packs per dayRecreational Drugs (Marijuana,Cocaine,etc.)
III. MENSTRUAL AND PREGNANCY HISTORY
YesNo


TamponsPads
YesNo
MildModerateSevere
YesNo
YesNo
When? Year End in Abortion End in Miscarriage Ectopic Pregnancy Infertility therapy required to conceive How long to conceive Born alive Is current partner the father
1st Pregnancy
2nd Pregnancy
3rd Pregnancy
4th Pregnancy
5th Pregnancy
YesNo
YesNoUnknown
   
YesNoUnknown
IV. CONTRACEPTIVE/SEXUAL HISTORY


NoneDiaphramWithdrawalFoam/JelliesCondomRhythmOther

Method Length of Use Reason for Discontinuation
YesNoN/A
YesNoN/A
YesNoN/A
YesNoN/A
V. HISTORY OF FERTILITY THERAPY (if applicable)
YesNo
hMG (Pergonal)progesteroneantibioticsclomiphene citrate (Sereophene, Clomid)bromocriptine (Parlodel)urofollitropin or FSH (Metrodin)estrogensprednisone (or cortisone-like drugs)GnRH or LHRH (Factrel)hCG (Profasi, A.P.L.)danazol (Danocrine)UnknownOther
BBTPostcoital TestHormonal Assays (FSH,LH prolactin,estrogen,DHEA testosterone,progesterone)Endometrial BiopsyHysterosalpingogramUltrasoundAntibodiesLaparoscopy,HysteroscopyMycoplasma/Chlamydia/Gonococcus CulturesProlactinThyroid TestsOther - SpecifyNone







YesNo
YesNo
YesNo
YesNo
YesNo
YesNoN/A
YesNo
YesNo
VI. FAMILY HISTORY
Age Any Health Problems Age of Menopause Check If N/A
Your Mother: N/A
Your Father: N/A
Your Sister(s): N/A
Your Brother(s): N/A

NoneCancer (specify)Thyroid Problems (including goiter)Hypertension (high blood pressure)Blood clotting disordersExcessive hair growthDiabetesKidney DiseaseTuberculosis (TB)Heart DiseaseObesityNeurologic (nerve) disordersOthers Specify











YesNoUnknown
VII. REVIEW OF SYMPTOMS
SeizuresMigrane headachesOther
Wear contact lensesEye disordersProblem with sense of smellOther
RashVitiligoProblems with skin pigmentationAcneOther
Chest painPalpitationsDiagnosed with Rheumatic feverHeart valve diseaseHigh blood pressure Mitral valve prolapseGiven prophylactic antibiotics before dental work or surgeryOther cardiovascular problem
Shortness of breathAsthma (date of last attack): BronchitisPneumoniaBlood in sputumOther
Nausea/vomitingBlood in stoolUlcersHepatitisConstipation Spastic colonPoor appetite/anorexiaOther
Bladder infections (cystitis)Kidney infectionGonorrhea Syphilis HerpesVaginal infectionsPelvic inflammatory disease (PID)Pelvic painOther genital or urinary disorder:
Unusual muscle weaknessDecreased energy/staminaRheumatoid arthritisLupus erythematosus (SLE)Other musculoskeletal problems:
Blood clotting disorderSickle cell anemia or traitOther
DiabetesHypoglycemiaThyroid diseaseExcessive growth of hair on various parts of the bodyUnexplained secretion of milk from breastsRapid weight gainRapid weight lossOther
YesNo
YesNo
YesNo
YesNo

Allergic to: Reaction:
1.
1.
1.
1.
1.
1.
1.
1.
YesNo
YesNo
YesNoNot Applicable
YesNoNot Applicable
YesNoNot Applicable
Share...Share on FacebookShare on Google+Tweet about this on TwitterPin on PinterestShare on LinkedIn