Confidential Medical History Form
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1
2Cherry Hill Women’s Center
CONFIDENTIAL MEDICAL HISTORY
Please read and answer the following questions as fully as possible
Name:
______ Age: __________
DOB:
__
Last time ate/drank:
Marital Status (please circle): single long-term partner married
divorced widowed
Race:
Religion:
(For statistical purposes at the request of the State of New Jersey)
Social History
If you drink alcoholic beverages, when was the last time?:
If you smoke cigarettes/cigars, how much do you smoke?:
If you have ever used recreational drugs, what kind:
last use:
Pregnancy History
Number of pregnancies (including this):
Vaginal deliveries:
Date of last:
Cesarean sections:
Dates of all:
Reasons:
Abortions:
Date of last:
D&C req’d:
Miscarriages:
Dates of all:
Living children:
Age of youngest child:
Any complications or hemorrhaging (excessive bleeding) with previous pregnancies, abortions or deliveries?
If yes, please explain:
Pain Management
Are you in pain? Yes___ No___
Circle how bad the pain is now 1-2-3-4-5-6-7-8-9-10
Where is the pain?____________________ How long have you had pain?_________________________
How frequent is the pain?____________________
What type of pain? Sharp Stabbing Ache Dull
What do you do to relieve the pain?_________________________________________________________
______________________________________________________________________________________
Gynecologic History
Have you been to the gynecologist before (please circle):
Yes
No
Have you ever had an abnormal pap smear? If yes, what year:
Have you ever had a sexually transmitted infection? If yes, what/when?___________________________
Clinician notes:
Medical/ Surgical History
Are you currently under medical care or do you have any medical conditions? :
____________________________________________________________________________________
Other than related to pregnancy, have you ever had surgery or an operation? :
______
______________________________________________________________________________
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Parent category: Medical