Patient Medical History Gynecological Form Page 2
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2SOCIAL HISTORY
Occupation:_____________________________________
Do you exercise?
YES / NO
Have you ever been sexually active?
YES / NO
Are you currently sexually active?
YES / NO
Did you have more than one sexual partner in the last year?
YES / NO
Have you ever smoked cigarettes or tobacco?
YES / NO
Do you currently smoke?
YES / NO
Amount per day:________
If former smoker, age quit smoking:_________
Do you use recreational or illicit drugs?
YES / NO
Type:_________________________
Do you drink alcohol?
YES / NO
Frequency:__________________________________
Have you ever been physically or sexually abused?
YES / NO
FAMILY HISTORY
(Please list family members diagnosed, if any:)
Anemia:________________________________________
Heart disease:_______________________________
Twin pregnancy:_________________________________
High cholesterol:_____________________________
Depression:_____________________________________
High blood pressure:__________________________
Diabetes:_______________________________________
Tuberculosis:_________________________________
Endometriosis:__________________________________
Psychiatric condition:__________________________
Menstrual problems:_____________________________
Blood clot in lung or leg:________________________
Thyroid disease:_________________________________
Stroke:_______________________________________
Kidney disease:__________________________________
Rheumatoid Arthritis:__________________________
Do you have any family history of any type of cancer?
YES / NO
If so, please list on the separate sheet provided.
REVIEW OF SYSTEMS:
Please circle current or on-going symptoms.
Cardiovascular/Respiratory
Genitourinary
Integumentary
Endocrine
Chest pain
Pelvic pain
Skin lump/mass
Excessive appetite
Shortness of breath
Vaginal discharge
Mole changes
Excessive sweating
Palpitations
Vaginal itching
Rashes
Excessive thirst
Wheezing
Vaginal odor
Breast lump/mass
Heat/Cold intolerance
Cough
Painful urination
Nipple discharge
Hair loss
Rheumatic fever
Frequent urination
Breast pain
Excess hair growth
Pneumonia
Night-time urination
Bronchitis
Missed period
Neurological
Hematology/Lymphatic
Change in periods
Numbness/Tingling
Anemia
Gastrointestinal
Heavy bleeding
Headaches
Blood transfusion
Nausea
Menstrual cramps
Seizures
Swollen glands
Vomiting
Painful intercourse
Localized weakness
Abdominal pain
Decreased desire
Dizziness
Musculoskeletal
Heartburn
Lumps/growths
Brain damage
Limited joint mobility
Constipation
Genital sores
Joint pain
Diarrhea
Bleeding after sex
Psychiatric
Muscle pain
Blood in stool
Blood in urine
Anxiety
Muscle weakness
Peptic ulcer
Leaking of urine
Depression
Back pain
Food intolerance
Kidney stones
Sleep problems
Difficulty switching position
Difficulty swallowing
Hot flashes
Suicidal thoughts
Hernia of abdomen
Disorder of Gallbladder
Night sweats
Anorexia
Vaginal dryness
Your Signature:_______________________________________________ Date:________________________________
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