Personal Medical History Template Page 2
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4Infection History
(If you answer yes to any question, please explain.)
Do you live with someone or are have you been exposed to someone with tuberculosis? Yes/No
Do you or your partner have a history of genital herpes? Yes/No
Have you had a rash or viral illness since your LMP? Yes/No
Do you or your partner have any history of STI (gonorrhea, Chlamydia, syphilis, HIV, etc)? Yes/No
Medical History
Have you had any of the medical problems listed below? If yes, please circle and give details.
Diabetes
Tuberculosis
High blood pressure
Depression
Stroke
Anxiety
High cholesterol
Eating disorder
Heart problems
Bipolar disorder
Hepatitis (A, B or C)
Alcoholism
Gallstones
Drug use/abuse
Kidney stones
Blood transfusion
Kidney infections
Anemia
Seizures
Gastrointestinal problems
Migraines
Victim of domestic violence
Thyroid problems
Victim of sexual abuse
Blood clots in your legs or lungs
Breast problems
Asthma
Cancer
Pneumonia
MRSA infection
Please use the lines below for any medical problems not listed: _________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Surgical History
Have you ever had any of the common surgeries listed below? If yes, please circle and give details.
Breast augmentation
Endometrial ablation
Breast reduction
Laparoscopy
Heart surgery (bypass, valve replacement)
Ovarian cystectomy
Appendectomy
Oophorectomy
Gall bladder (cholecystectomy)
Tubal ligation
Weight loss surgery (bariatric)
Cervical procedure (LEEP, cone, etc)
Bowel surgery
Joint replacement
Hernia repair
Excision of skin cancer
Uterine surgery
Thyroidectomy
Cesarean section
Back surgery (laminectomy, fusion, rods, etc)
D&C
Please use the lines below for any surgeries not listed: ________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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