Women's History
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Provider Name
*
Please provide the patient's full legal name as it appears on their driver's license, state identification card, or government issued identification card.
Birth Month
January
February
March
April
May
June
July
August
September
October
November
December
Birth Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Year
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
Women's History
* Required Information
Tobacco Use
What is your smoking status?
Current (every day)
In the past
Current (some days)
Never
How many packs per day do you smoke?
How many packs per day did you smoke?
Less than 1
1-2
More than 2
How many years have you smoked?
How many years did you smoke?
5 or less
6-10
More than 10
Do you use other tobacco products?
Currently
In the past
Never
Are you exposed to passive (secondhand) smoke?
Yes
No
Alcohol Use
Do you consume alcohol?
Never
In the past
Currently
Type(s):
Beer
Wine
Liquor
How often do you drink?
Number of times:
1
2
3
4
5
6
7 or more
Per:
Week
Month
Year
Drug Use
Do you use street drugs?
None
Current
Previous
Prefer to discuss with physician
Type(s):
Marijuana
Meth
Crack
LSD
Cocaine
Speed
PCP
Heroin
Prescriptions not prescribed to you
Risk Factors
Please answer yes or no if you or your partner have had any of the following: IV drug use, more than one sexual partner, unprotected sexual contact, contact with contaminated injection equipment, multiple blood transfusions, HIV or Hepatitis B.
Yes
No
Caffeine
Drinks per day:
None
Occasionally
1-2
3-4
5-6
7 or more
Type(s):
Coffee
Tea
Soft drinks
Exercise
Times per week:
Never
Occasionally
1-2
3-4
5-6
7 or more
Type(s) of exercise:
Bicycling
Running
Swimming
Walking
Aerobics
Other
Other
How often do you wear a seatbelt?
Always
Almost always
Occasionally
Never
Sun exposure
Rarely
Occasionally
Frequently
Do you feel safe at home?
Yes
No
In the past year, have you been hit, punched, kicked or slapped by anyone?
Yes
No
Surgical History
*
Do you have any surgical history?
Yes
No
Appendectomy
Bladder
Bowel
Breast biopsy/Lumpectomy
Cervical
Colon
Cosmetic
Gallbladder removal
Hysterectomy (abdominal)
Hysterectomy (vaginal)
Incontinence
Laparoscopy
Mastectomy
Ovary removal
Rectal
Tonsillectomy
Tubal ligation
Other
Past Medical History
*
Do you have any medical history problems?
Yes
No
Anemia
Anesthesia complications
Anxiety
Asthma
Autoimmune disorder
Bladder infections
Bleeding between periods
Bleeding disorder
Blood clots
Blood transfusions
Bothersome loss of urine
Cancer (breast)
Cancer (cervical)
Cancer (colon)
Cancer (lung)
Cancer (ovarian)
Cancer (uterine)
Chlamydia
Depression
DES exposure
Diabetes
Emotional neglect/abuse
Endometriosis
Epilepsy/Seizures
Gallbladder disorder
Gastrointestinal disorder
Genital warts
Gonorrhea
Heart disease
Hepatitis
Herpes
High blood pressure
High cholesterol
HIV exposure
HPV (Human Papilloma Virus)
Infertility
Kidney disease
Liver disease
Major accident
Migraine headaches
Mitral valve prolapse
Neurologic disorder
Non-surgical hospitalization
Osteoporosis/Osteopenia
Ovarian cysts
Pain/Bleeding during intercourse
Physical neglect/abuse
PMS
Psychiatric care/hospitalization
Rheumatic fever
RH sensitized
Severe cramping
Severe pain during period
Sexual difficulty
Sickle cell trait/disease
Stroke/CVA of the brain
Syphilis
Thyroid disorder
Trichomoniasis
Tumors
Urinary problems
Uterine abnormality
Uterine fibroids
Vaginal discharge
Vaginal infection
Varicose veins
Weight disorder
History of taking antibiotics (for dental work)
Other
Menstrual History
Menstrual period:
N/A
Light to moderate flow
Excessive cramping
Excessive flow
Length of flow (on average):
0-4 days
5-7 days
8 or more days
Cycle regularity (from 1st day of period to start of next period):
Regular
Irregular
No periods
Current contraception (mark all that apply):
Abstinence
Condom
Depo-Provera©
Foam
Hysterectomy
IUD
Patch
Pill
Rhythm
Ring
Tubal sterilization
Vasectomy
Other
None
Prior contraception (mark all that apply):
Abstinence
Condom
Depo-Provera©
Foam
Hysterectomy
IUD
Patch
Pill
Rhythm
Ring
Tubal sterilization
Vasectomy
Other
None
Sexual History
Have you ever had sex?
Yes
No
Did you begin having sex before the age of 18?
Yes
No
Are you currently sexually active?
Yes
No
Are you planning a pregnancy this year?
Yes
No
Pregnancy History
Number of pregnancies (include current)
0
1
2
3
4
5
6
7
8
9
10 or more
Number of live births
0
1
2
3
4
5
6
7
8
9
10 or more
Number of stillbirths
0
1
2
3
4
5
6
7
8
9
10 or more
Number of vaginal deliveries
0
1
2
3
4
5
6
7
8
9
10 or more
Number of cesarean sections
0
1
2
3
4
5
6
7
8
9
10 or more
Number of miscarriages
0
1
2
3
4
5
6
7
8
9
10 or more
Number of abortions
0
1
2
3
4
5
6
7
8
9
10 or more
Number of ectopics (tubal pregnancy)
0
1
2
3
4
5
6
7
8
9
10 or more
Have you had any complications?
Bleeding
Diabetes
High blood pressure
Pre-term delivery
Breech
Premature labor
Pre-term rupture of membrane(s)
Other
None
Family Medical History
*
Do you have a
family
history of illnesses?
Yes
No
Unknown
Breast cancer
Mother
Father
Sister
Brother
Daughter
Son
Lung cancer
Mother
Father
Sister
Brother
Daughter
Son
Uterine cancer
Mother
Sister
Daughter
Other cancer
Mother
Father
Sister
Brother
Daughter
Son
PMS
Mother
Sister
Daughter
Endometriosis
Mother
Sister
Daughter
Cesarean section
Mother
Sister
Daughter
Bleeding disorder
Mother
Father
Sister
Brother
Daughter
Son
Sickle cell disease
Mother
Father
Sister
Brother
Daughter
Son
Blood clots
Mother
Father
Sister
Brother
Daughter
Son
Varicose veins
Mother
Father
Sister
Brother
Daughter
Son
High blood pressure
Mother
Father
Sister
Brother
Daughter
Son
Heart disease
Mother
Father
Sister
Brother
Daughter
Son
Heart attack
Mother
Father
Sister
Brother
Daughter
Son
Thyroid disease
Mother
Father
Sister
Brother
Daughter
Son
Diabetes
Mother
Father
Sister
Brother
Daughter
Son
Weight disorders
Mother
Father
Sister
Brother
Daughter
Son
Osteoporosis / Osteopenia
Mother
Father
Sister
Brother
Daughter
Son
Tuberculosis
Mother
Father
Sister
Brother
Daughter
Son
Respiratory disease
Mother
Father
Sister
Brother
Daughter
Son
Kidney disease
Mother
Father
Sister
Brother
Daughter
Son
Migraine headaches
Mother
Father
Sister
Brother
Daughter
Son
Seizures / Epilepsy
Mother
Father
Sister
Brother
Daughter
Son
Stroke
Mother
Father
Sister
Brother
Daughter
Son
Depression / Anxiety
Mother
Father
Sister
Brother
Daughter
Son
Psychiatric care / Hospitalization
Mother
Father
Sister
Brother
Daughter
Son
Other
Mother
Father
Sister
Brother
Daughter
Son
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Form Number 845
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