Patients Name _____________________________________
Date of Birth ____________________ Today's Date __________________
Personal Medical History - Check if YOU have had any of the illnesses or medical problems listed:
| Anemia
|
||
| Asthma
|
||
| Alcoholism
|
||
| Cancer
|
Type
|
|
| Depression/Mental Illness
|
||
| Diabetes
|
||
| Epilepsy/Convulsions
|
||
| Eye Problems/Glaucoma
|
||
| Heart Disease
|
||
| High Blood Pressure
|
||
| High Cholesterol
|
||
| HIV/AIDS
|
||
| Kidney/Bladder Problems
|
||
| Liver
Disease/Hepatitis/Jaundice
|
||
| Lung Disease/Tuberculosis
|
||
| Migraine Headaches
|
||
| Phlebitis/Blood Clots
|
||
| Skin Problems
|
||
| Smoker
|
||
| Stroke
|
||
| Substance Abuse/Drug Abuse
|
||
| Thyroid
|
||
| Ulcers
|
||
| Uncontrolled Bleeding
|
| Gynecologic History | ||
| Previous abnormal pap
smears (yes or no)
|
||
| Previous abnormal
mammogram (yes or no)
|
||
| Approximate Date of last
mammogram
|
Where completed (circle
one): Fryecare // Catawba Imaging
Caldwell/Lenoir // Blue Ridge Radiology // Other |
|
| Previous STD/Venereal
Disease (chlamydia, gonorrhea, HPV, herpes) (yes or
no)
|
| Obstetrical History |
|
|
| Number of pregnancies |
|
|
| Number of deliveries
|
||
| Number of Living Children
|
||
| History of diabetes in
pregnancy (yes or no)
|
||
| History of high blood
pressure in pregnancy (yes or no)
|
||
| Complications in pregnancy (yes or no) |
|
|
| List of Surgeries and Approximate Dates |
|
|
|
|
|
|
|
|
|
|
|
|
|
| List of Medications: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Allergies to Medications or Latex: Please List |
|
|
|
|
|
|
|
|
|
|
|
|
|
Family History - Check if you have relatives, living or deceased, with any of the listed illnesses. Also state which relative is involved.
| Family History |
X |
Relative Affected |
| Breast Cancer
|
||
| Uterine Cancer
|
||
| Ovarian Cancer
|
||
| Cervical Cancer
|
||
| Colon Cancer
|
||
| Diabetes
|
||
| Heart Disease - for
example heart attack or bypass surgery, pacemaker
etc.
|
||
| History of blood clots
requiring medication
|
||
| High cholesterol
|
||
| Other Cancer
(type_____________________)
|
||
| Other Problems
(______________________)
|