Westside OB/GYN Patient History Form

NG GYN Comprehensive History FormPlease indicate if you have had any of the following surgeries or treatments.Please list the date next to any applicable surgery treatment.AngioplastyAppendectomyArthroscopyBack SurgeryBilateral oophorectomy (removal of both ovaries)Bilateral tubal ligation (tubal sterilization procedure)Blood transfusionBreast AugmentationBreast ReductionCABG (cardiac bypass)Cardiac PacemakerChemotherapyCholecystectomy (gallbladder removed)Past Surgical HistoryD & C (dilation and curettage)Gastric bypassHernia repairHip replacementHysterectomyKnee replacementMastectomyMyomectomyPubic sling (bladder neck suspension)Radiation therapyThyroidectomyOther surgeries (list below)Other surgeries: ______________________________________________________________________________________________________________________________________________________________________Social HistoryMarital Status: Single Married Widowed DivorcedDo you drink alcoholic beverages? Yes No Amount per week: ______________If you drink, what type of alcohol do you drink? __________________________________Are you very active or get regular exercise? Yes NoHow many times a week do you exercise? _____________What type of exercise do you do? (example: weights, jogging, basketball, etc) _________________________________Do you consume caffeine? Yes No Amount per day: _______________If you do, what type? (example: coffee, tea, chocolate, etc.) _______________________________________________Do you always wear your seatbelt when in a motor vehicle? Yes NoUpdated 6/25/14

NG GYN Comprehensive History FormFamily HistoryPlease indicate with a check any of the following medical problems within your family history:M = Mother F = Father S/B = Sister or BrotherIn the GM/GF columns (Grandmother or Grandfather) please indicate with a P for Paternal or an M for Maternal.M F S B GM GF M F S B GM GFAlcoholismMental IllnessBlood clots (DVT or PE)Ovarian CancerBreast CancerProstate CancerColon CancerUterine CancerDiabetesOther:Heart DiseaseAre you experiencing any of the following symptoms related to today’s visit? Please mark all that apply.Constitutional: HEENT Resp: Cardio: Chills Fatigue Fever Ear pain Sinus pressure Sore Throat Cough Shortness of breath Wheezing Chest Pain Swelling in legs Palpitations Night sweats Weight gain Weight loss Visual changesGI: GU: Reproductive: Integumentary Abdominal pain Blood in stools Constipation Diarrhea Heartburn Nausea Vomiting Pain with urination Blood in the urine Urinary frequency Leaking urine Painful menses Pain with intercourse Heavy menstrual cycles Hot flashes Irregular menstrual cycles Vaginal discharge Vaginal dryness Breast discharge Breast lump Hair loss Hair growth on face orabdomenNeuro: Mood: Heme/Lymph: MS: Numbness Weakness Headache Anxiety Depression Sleeping problem Bleeding Easily Bruising Easily Swelling lymph nodesPlease list any other concerns: Back pain Joint pain Joint swellingUpdated 6/25/14