Here is a patient's medical history form from The Center of Innovative GYN Care.

1. Patient: First Name _______________________________ Last Name _____________________________________
PAST MEDICAL HISTORY
Do you have any of the following?
Heart or Vascular □ YES □ NO
□ Hypertension
□ High Cholesterol
□ Heart attack
□ Stroke
□ Blood clot
□ Other_______________________
Breathing or lung □ YES □ NO
□ Asthma
□ COPD
□ Pneumonia
□ Other_______________________
Endocrine □ YES □ NO
□ Hypothyroid
□ Hyperthyroid
□ Diabetes
□ Other_______________________
Mood or Mental □ YES □ NO
□ Depression
□ Anxiety
□ Bipolar
□ Schizophrenia
□ Eating Disorder
□ Other_______________________
Blood □ YES □ NO
□ Anemia
□ Sickle Cell
□ Other_______________________
Neurologic □ YES □ NO
□ Migraine
□ Headaches
□ Multiple Sclerosis
□ Seizure d/o
□ Other_______________________
Urinary □ YES □ NO
□ Incontinence
□ Overactive Bladder
□ Other_______________________
Stomach or GI □ YES □ NO
□ Reflux
□ Ulcer
□ Constipation
□ Irritable Bowel
□ Other_______________________
Autoimmune □ YES □ NO
□ Arthritis
□ Other_______________________
Cancer □ YES □ NO
□ Breast
□ Colon
□ Skin
□ Uterus
□ Cervix
□ Ovaries
□ Other_______________________
Other ________________________________

2. Patient: First Name _______________________________ Last Name _____________________________________
PAST MEDICAL HISTORY
When was your last:
Colonoscopy? Month/Year: ______________________________ □ I’ve never had one
Bone Density Scan? Month/Year: ______________________________ □ I’ve never had one
Mammogram? Month/Year: ______________________________ □ I’ve never had one
Have you ever had surgery? □ YES □ NO
Year: _____________ Type of surgery: __________________________________________________________
Year: _____________ Type of surgery: __________________________________________________________
Year: _____________ Type of surgery: __________________________________________________________
Year: _____________ Type of surgery: __________________________________________________________
Year: _____________ Type of surgery: __________________________________________________________
OB/GYN HISTORY
Have you ever been pregnant? □ NO □ YES
Vaginal deliveries # ____
Cesarean deliveries # ____
Miscarriages # ____
Abortions # ____
When was your last pap smear? Month/Year: _______________________ □ I’ve never had one
Have you ever had an abnormal pap? □ NO □ YES
When? _____________________________ What was done about it? ____________________________
________________________________________________________________________________________________
Any history of recurrent vaginal infections? □ NO □ YES
Please explain: ______________________________________________________________________________

3. Patient: First Name _______________________________ Last Name _____________________________________
Any history of sexually transmitted infections? □ NO □ YES
Please explain: ______________________________________________________________________________
Any history of pelvic inflammatory disease? □ NO □ YES
Please explain: ______________________________________________________________________________
Have you ever used prescription birth control? □ NO □ YES
What kind? (check all that apply)
□ Pills
□ Patch
□ Ring
□ Injection
□ IUD
□ Other ___________________
MEDICATIONS
Do you take any medications or supplements? □ NO □ YES
Please list all current medications and supplements including the dose:
Medication: __________________________________ Dose: __________________ How often: _______________
Medication: __________________________________ Dose: __________________ How often: _______________
Medication: __________________________________ Dose: __________________ How often: _______________
Medication: __________________________________ Dose: __________________ How often: _______________
Medication: __________________________________ Dose: __________________ How often: _______________
Medication: __________________________________ Dose: __________________ How often: _______________
Do you have any drug allergies? □ NO □ YES
Please list all drug allergies and the reaction:
Drug: ______________________________ Reaction: ______________________________________________________
Drug: ______________________________ Reaction: ______________________________________________________
Drug: ______________________________ Reaction: ______________________________________________________
Drug: ______________________________ Reaction: ______________________________________________________
Drug: ______________________________ Reaction: ______________________________________________________
Drug: ______________________________ Reaction: ______________________________________________________

4. Patient: First Name _______________________________ Last Name _____________________________________
SOCIAL HISTORY
Do you drink alcohol? □ No □ Occasionally □ Daily
Do you smoke? □ No □ Yes
How many per day? ___ How old were you when you started smoking? ____
Do you use drugs? □ No □ Marijuana □ Cocaine □ Heroin □ Other: __________________
FAMILY HISTORY
Breast cancer: □ No □ Yes If Yes: Who has had breast cancer? ____________________________
Uterine cancer: □ No □ Yes If Yes: Who has had uterine cancer? __________________________
Ovarian cancer: □ No □ Yes If Yes: Who has had ovarian cancer? __________________________
Heart disease: □ No □ Yes If Yes: Who has had heart disease? ___________________________
Diabetes: □ No □ Yes If Yes: Who has had diabetes? ________________________________
Other: □ No □ Yes If Yes: Who has had other? ___________________________________