Petoskey Gynecology & Infertility
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New Patient Health History
Date
MM slash DD slash YYYY
Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Age
Primary Care Doctor
(Required)
Date Last Seen
Approximate
Reason for this Visit
Yearly Well Woman Visit
Problem
Describe Your Current Problem
Date of Last Menstrual Period
Month
Day
Year
Have you had a hysterectomy?
Yes
No
Are you having Intercourse
Yes
No
Are you doing anything to prevent pregnancy?
Birth Control Pills
Patches
Condoms
Spermicides
Tubal
Vasectomy
Rhythm or Withdrawl
Other
Check all that apply
Other- please describe
Date of Last Pap Smear
MM slash DD slash YYYY
History of Abnormal Pap Smears?
Yes
No
When was your abnormal pap?
What was your treatment?
Date of Last Mammogram
MM slash DD slash YYYY
History of Abnormal Mammograms?
Yes
No
Relationship Status
Married
Single
Separated
Divorced
Widowed
Female Partner
Occupation
Current Medications (include over the counter and supplements)
Medication
Dose (per day)
Add
Remove
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Medication Allergies
Add
Remove
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Other Allergies
Add
Remove
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Surgeries
Add
Remove
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Other Hospitalizations
Add
Remove
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Current Medical Conditions:
Do you currently or have had in the past any mood disorders?
Depression
Anxiety
Manic Depression
Other
Other Mood Disorder:
Obstetric History
Number of pregnancies
Number of deliveries
Method of birth(s)
Vaginal
C-Section
Both
Current ages of children
Who in your family has had any of these Problems?
High Blood Pressure
Diabetes
Early stroke or Heart Attack
Blood Clots (phlebitis)
High Cholesterol
Osteoperosis
Additional Questions
Do you currently use tobacco?
Yes
No
Do you wish you have help or get information about quitting?
Yes
No
Have you ever used any of these resources to help try to quit?
Medication
Patches
Counseling
Support Groups
Other
Other- please describe
Do you drink alcohol?
yes
no
How many drinks per week on average?
Have you been treated for a drinking problem in the past?
yes
no
Do you think you have a drinking problem?
yes
no
unsure
Do you drink caffienated drinks?
yes
no
How many drinks per day?
Have you used illegal drugs or abused narcotics?
yes
no
What kind, and when?
Do you get regular exercise?
yes
no
How many times per week do you exercise 30 minutes or more?
Do you follow a diet plan for weight loss?
yes
no
What type of diet do you follow?
Email
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