Women’s Health Center PERSONAL AND FAMILY MEDICAL HISTORY Date: __________________________ Allergies: _____________________________________________________________________________________________
______________________________________________________________________________________________________
Medications — Please list all of the medications you are taking, including any vitamins, herbal medicines and “over-the-counter” medications. Name of Medication Frequency Medical History — Please check (;) if you have had any of the following conditions. None
D.V.T. or P.E. (blood clots) G.E.R.D. (reflux)
Bleeding or clotting disorder Liver disease or hepatitis
Other: ____________________________________________________________________________________________
Obstetric and Gynecologic History
Total # of pregnancies: _____________ # of vaginal deliveries: ______________ # of C-sections: ___________________
# of children: _____________________ # of miscarriages: _________________ # of abortions: ____________________
Are you in menopause? Yes No If “no,” please complete the following:
Date of last menstrual period: ______________ # of days between cycles (first day of one to the first day of the next): _____
Date of last Pap Smear: _____________ Have you had any abnormal Pap Smears? Yes No If “yes,” when? _______________
Are you currently sexually active? Yes No Total number of partners in your lifetime: 0 1-5 6-10 >10
My partner(s) is(are): Male Female Both
Have you ever had a sexually transmitted infection or pelvic inflammatory disease? Yes No
If “yes,” which one(s): _________________________________________________________________________________
List any gynecologic procedures or surgeries that you have had: _________________________________________________
____________________________________________________________________________________________________
Method of Birth Control
Other: ____________________________________________________________________
Immunizations — Please provide your most recent immunization dates for .
Tetanus/diphtheria: ________________________________ Hepatitis B: _________________________________________
Tetanus/dipththeria/pertussis _________________________ Varicella: ___________________________________________
Have you ever had chicken pox? Yes No
Please check (;) if you currently have any of the following:Surgical History Please list all the surgeries you have had, including the dates: ___________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Social History Occupation: ___________________________________________________________________________________________
Are you? Married Single Divorced Widowed Separated Significant other Other: ________________
Highest level of education: College High School G.E.D. Other:___________________________________________________________
Do you smoke? Yes No If “yes,” how many cigarettes per day and for how long? _______________________________
Do you drink? Yes No If “yes,” the number of drinks per day:______________________________________________
Have you ever used any recreational drug? Yes No If “yes,” which one(s) and when? ______________________________________
Do you get regular exercise Yes No If “yes,” how often? _________________________________________________
Do you have any dietary restrictions? Yes No If “yes,” what restrictions?_____________________________________
Do you want to discuss abuse? Yes No
Family Medical History Maternal Paternal Condition Father Grandfather/ Grandfather/ Grandmother Grandmother
REVISTA PORTUGUESA DE Arqueologia . volume 1. número 2. 1998 O naufrágio da fragata espanhola Nuestra Señora de las Mercedes, afundada pelos ingleses ao largo do Cabo de Sta. Maria, em 1804 Afundada em 1804 pela Marinha Inglesa ao largo da costa do Algarve, a fragata Nuestra Señora de las Mercedes transformou-se num mito dos caçadores de tesouros,Embora a sua carga dificilmente possa c
AMERICAN BLASPHEMY: THE HONEYMOONERS By Michael Ventura March 31, 2000 In 1955, General Motors became the first corporation to earn more than $1 billion in one year . Thorazine was developed . James Dean died in a car crash . Blackboard Jungle introduced the (white) world to a new music with "Rock Around the Clock" . Marilyn Monroe starred in The Seven Year Itch , a film th
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