Age at
1st Menstrual Period _______ Number of Days of Usual
Menstrual Flow _________
Number of Days From the Start of One
Period to the Start of the Next ________
Date Most Recent Period
Began: Month _____ Day _____ Year _____
Date Period Before
Last Began: Month _____ Day _____ Year _____
Date of Last Pap
Test: Month _____ Day _____ Year _____
Please
Circle One:
Amount of Pain With Your Period:
None Reasonable Severe
Amount of Flow
With Your Period: None Reasonable Severe
Do
You Have Clots With Your Period? No Yes
Do You Use Tampons? No Yes
Do You Spot or Bleed Between Periods: No Yes
Do You Bleed After Intercourse? No Yes
Do You Have Any Discharge From Nipples? No Yes
Surgical History: Circle Any and Give Date After Each
D&C ___________ Leep ____________ Hemorrhoids ___________ Hysterectomy ___________
Cryosurgery ____________ Hernia ___________ Ovary ___________
Laser Surgery ____________ Breast Biopsy ___________ Tubes ___________
Hysteroscopy ____________ Thyroid ___________ Cesarean Section ___________
Laparoscopy ____________ Cervical Biopsy ___________ Appendix ____________
Gall Bladder ____________ Colposcopy ___________ Other (specify) _______________
Medical History: Circle Any You Have Had
Aids/ARC Chlamydia Genital Herpes
Phlebitis
Anemia Diabetes
Hepatitis Or Jaundice Rheumatic Fever
Arthritis
Endometriosis High Blood Pressure Skin Disease
Asthma Epilepsy Infected Tubes/Ovaries Syphilis
Bladder Disease Genital Warts Kidney
Disease Thyroid Disease
Bleeding Problems
Gonorrhea Liver Disease Tuberculosis
Cancer(specify)____________ Heart Disease Mental Disease
Other __________
Have Your Grandparents,
Parents, Brothers, Sisters, Aunts, Uncles or Children Had (specify which relative):
Breast Cancer __________________ Blood Pressure _______________
Other Cancer __________________ Inherited Disease _______________
Birth Defects __________________ Mental Retardation _______________
Diabetes __________________ Muscular Dystrophy _______________
Heart Disease __________________ Psychiatric Disorder _______________
Stillbirths __________________ Blood Diseases _______________
Tuberculosis __________________ Down’s Syndrome _______________ Circle Any of the Following You Have Had During
the Past 6 Months:
Appetite Loss
Weight Loss Mucus In Stool
Unusual Hair
Growth/Loss Fainting Hearing Trouble
Cough With Blood Dizziness Depression
Cough With Phlegm Hot Flashes Abdominal Pain
Excessive Weakness Black Stool Bloody Urine
Painful Urination Vision Trouble Severe Headaches
Swollen Hands Or Feet Hoarseness Chest Pain
Heart Throbbing Blood In Stool Diarrhea
Difficulty Swallowing Constipation Nausea
Change In Frequency Of Bowel Movements Short Of Breath
Eye Pain Chills And Fever Breast Lump
Nose Bleeds Weight Gain Urine Loss With Cough Or Sneeze
Sudden Urge To Urinate Ringing Ears
Circle Your Present Method of Birth Control:
The Pill Rhythm Intrauterine Device (I.U.D.) Jelly
Sponge Withdrawal Foam
Douche Condom Vaginal Tablets Diaphragm
Vasectomy Tubal Ligation
Cervical Cap Other:_____________________
None
List Any Medications You Take Now:
1) _______________________________________ 2) ______________________________________
3) _______________________________________4) _______________________________
Are You Allergic To Any Medications? If Yes, Please List:
1) ___________________________ 2) ___________________________
3) ____________________ 4) _____________________5) _______________________
Have You Had Your Cholesterol Level Checked Recently? _____ Normal ______Abnormal
______
Have You Ever Had a German Measles Vaccine? Yes ______
No ______
Have You Had a German Measles Test? Yes ______ No
______
Do You Smoke? Yes ______ No ______
If Yes, How Many Packs Per Day? ______
Usual Weight _____________ Current Weight _____________ Height _______________
Have You Ever Had a Mammogram? ________ What Year? ________ Where? ________
Have You Ever Had a Blood Transfusion? Yes _______ No _______
Have You Ever Had Trouble Stopping Bleeding? Yes _______ No _______
Have You Had Any Serious or Chronic Illness? Yes _______ No _______
If Yes, Explain: ________________________________________________________________
Have You Been in the Hospital for Anything Other Than Surgery or Delivery? Yes _______ No ________
If Yes, Please Explain: _____________________________________________________________________
_______________________________________________________________________________________
Are You Having Difficulty Getting Pregnant? Yes _______ No _______
Do You Drink Alcohol Daily? Yes _______ No _______
Do You Wish to be Tested for Sexually
Transmitted Infections?
Yes _______ No _______
Do You Wish to Discuss Any Sexual Problems?
Yes _______ No _______
Do You Experience Orgasms? Yes _______
No _______
Do You Have Pain With Intercourse? Yes _______ No
_______
Do You Wish to be Tested for the AIDS Virus? Yes _______
No _______
Pregnancy Complications: Circle Any You Have Had:
Anemia Diabetes Placenta Previa Toxemia
Bleeding High Blood Pressure Premature Labor Other:
Cesarean
Section Jaundice Preeclampsia
Convulsion Kidney/Bladder Disease
Rh Disease
Previous Pregnancies And Miscarriages Or Abortions:
