Sp-fpica-8.04.indd

Name: __________________________________________________ Today’s Date: _______________ Date of Birth: _______________________ Social Security #: ___________________________________ Street address: _________________________________________________________________________ City: __________________________________________ State: ______________ Zip:_____________ Phone numbers: Home _____________________________ Cell______________________________ Do you have an email address you can share with us?________________________________________ We would like to stay in contact with you at all times. Please provide us with a summer residence location if you have one: ________________________________________________________________ Patient employed by: __________________________________________________________________ Business address: _____________________________________________________________________ Business phone: ______________________________________________________________________ Marital status: (please circle) Married Divorced Single Widow Living with Sig. Other Spouse’s Name: ______________________________________________________________________ Spouse’s date of birth: _______________________ Social Security #: _________________________ Spouse employed by: __________________________ Business phone:_________________________ In case of emergency, whom should we notify? _________________________________________ Phone number(s): _________________________________________________________________ Signature: _____________________________________________ Date: __________________________ y? f it is a problem, please describe the symptoms & be specifi c: _______________________________________________________________________ ______________________________________________________________________________
OB HISTORY
1. How many times have you been pregnant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____________2. How many miscarriages have you had? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____________3. How many abortions have you had? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____________4. Have you had any Tubal/Ectopic pregnancies? . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____________5. How many vaginal deliveries have you had? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____________6. How many Cesarean Sections have you had? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____________7. Have you had any premature deliveries? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____________8. Have you had any babies weighing less than 5 lb 8 oz at birth? . . . . . . . . . . . . ____________9. How many full term deliveries? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____________10. Have you had any twin births? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____________11. Did you have any complications with your pregnancies? ❏ YES ❏ NO If yes, list: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ GYN HISTORY
3. What type of contraception are you currently using? (CIRCLE BELOW) Pills Tubal Ligation Condoms Withdrawal Depo Provera IUD Foam Vasectomy Diaphragm Implants Other __________________4. What type of contraception have you used in the past? (CIRCLE BELOW) Pills Tubal Ligation Condoms Withdrawal Depo Provera IUD Foam Vasectomy Diaphragm Implants Other __________________5. Are you having any problems with your method of Birth Control? ❏ YES ❏ NO6. Have you ever had any vaginal, cervical and/or tubal infection? If yes, please check below: ❏ Yeast ❏ Gardnerella ❏ Syphllis ❏ Condyloma ❏ Bacterial Vaginitis ❏ PID ❏ Herpes ❏ Trichomonas ❏ Chlamydia ❏ Gonorrhea ❏ Warts ❏ Other _________7. Date of last pap smear? ________________________________________________________8. Have you ever had an abnormal pap smear? If yes, how was it treated? Please check below: ❏ Repeated Pap Smear ❏ Colposcopy ❏ Laser Surgery ❏ Cone Biopsy ❏ Cryosurgery (freezing) ❏ Hysterectomy ❏ Loop Excision9. Do you have trouble leaking urine? 10. Do you have any breast lumps, tenderness or discharge? Date of last mammogram ____________________________________________________11. Do you do breast self exams? If yes, any treatment?________________________________________________________13. Do you have any hot fl ashes or menopausal symptoms? 15. Do you have a history of infertility? 16. Do you have a history of DES exposure? MENSTRUAL HISTORY
1. If you no longer have periods, please state reason: __________________________________2. First day of last period: ________________________________________________________3. How many days does your period last? ___________________________________________4. Are your periods regular? 5. How many days from the start of one period to the start of the next period? _____________6. Has the fl ow changed in any way? ___________ If so, how? ___________________________7. Do you have any bleeding between periods? 8. Do you have any cramping with your periods? If yes, circle one: mild moderate severe9. Medicine taken for cramps? ____________________________________________________ SOCIAL HISTORY
If yes, # per day? _________________________ Number of years? ____________________2. Do you use street drugs? If yes, how much per day?______________________________________________________ PAST MEDICAL HISTORY
6. Have you ever been treated for psychiatric problems? 9. Have you ever had a urinary tract infection? 10. Have you ever had hepatitis/liver disease? 11. Have you ever had varicosities/phlebitis? 14. Have you ever had any blood transfusions? If yes, please list:_____________________________________________________________17. Please list any GYN surgeries:______________________________________________________________________________ ______________________________________________________________________________18. Please list any other operations/hospitalizations (include year & reason):______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________19. Have you had any anesthesia complications? If yes, please list:_____________________________________________________________20. Have you ever been anemic? 21. Do you have an Internist or Family doctor? Please list name, phone number:______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________22. Are you currently on any medications? If yes, please list with dosage: __________________________________________________23. Have you had your cholesterol checked? If yes, date last checked: ______________________________________________________ Was it normal? If yes, what type? ____________________________________________________________25. Do you have Lupus, Scleroderma or similar diseases? If yes, please describe: ________________________________________________________ FAMILY HISTORY
1. Do you have a family history of breast cancer? If yes, whom?_______________________________________________________________2. Do you have a family history of colon cancer? If yes, whom?_______________________________________________________________3. Do you have a family history of ovarian cancer? If yes, whom?_______________________________________________________________4. Do you have a family history of osteoporosis? If yes, whom?_______________________________________________________________5. Do you have a family history of diabetes? If yes, whom?_______________________________________________________________6. Do you have a family history of hypertension? If yes, whom?_______________________________________________________________7. Do you have a family history of heart disease? If yes, whom?_______________________________________________________________8. Do you have a family history of kidney disease? If yes, whom?_______________________________________________________________

Source: http://www.icambartissmd.com/forms/cert_female_assessment_form.pdf