Legacy Obstetrics & Gynecology MEDICAL HISTORY FORM
PATIENT INFORMATION:
NAME		DATE
BIRTHDATE(MM/DD/YY)		AGE
HOME #		WORK #
SS#		RACE
MARITAL STATUS	Single   Married   Divorced   Widow
EDUCATION		OCCUPATION
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REASON FOR VISIT?
ALLERGIES TO MEDICINES
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MENSTRUAL HISTORY:
Date of Last Menstrual Period    UNKNOWN (MM/DD/YY)		How long does your period last?  Days
Usual interval between periods?    Days		Age of first menstrual period
Describe any changes in your menstrual pattern
Do you experience any of the following?  Painful periods  Abnormal bleeding  Hot flashes  Abnormal discharge
Are you sexually active?  If so, any problems?
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PAP SMEAR Date of Last Pap smear  Result Normal  Abnormal		MAMMOGRAM Date of Last Pap smear  Result Normal  Abnormal
CONTRACEPTIVE HISTORY:
Current Method Birth Control Pills  Patch  Depo Provera  IUD  Tubal Ligation  Condoms  Other
PREGNANCY HISTORY:
Total Pregnancies    Full Term    Premature    Miscarriages  Abortions    Ectopics    Multiple Births    Living Children
PAST PREGNANCIES
No. Date M/Y GA Weeks Length of Labor Birth Weight Sex Type of Delivery Anesthesia 1. 2. 3. 4. 5. 6. 7. 8.
Do you experience any of the following?  Preterm Labor    Preeclampsia    Gestational Diabetes    IUGR    Incompetent cervix    GBS    Severe Bleeding
Comments (Please specify complications and which pregnancy)
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PAST MEDICAL AND FAMILY HISTORY Please check if you (P = Patient) or any blood relative (F = Family) has/had any of the following:
Heart Disease P F Anemia/ Blood Disorder P F Chlamydia P F High Blood Pressure P F Diabetes P F Uterine Fibroids P F Phlebitis P F Gonorrhea P F Lung Disease P F Herpes (HSV) P F Syphilis P F Pulmonary Embolus P F HIV/AIDS P F Urinary Incontinence P F Jaundice/Hepatitis P F Trichomonas P F Asthma P F Skin Disorder P F Group B Strep P F Tuberculosis P F Thyroid Disease P F Pyelonephritis P F Breast Disease P F Headaches/Migraine P F Autoimmune Disease P F Gall Bladder Disease P F Seizure Disorder P F Major Accident P F Bowel Disorder P F Genetic Disorder P F Cancer P F Kidney Disease P F Peptic Ulcer P F
List previous Surgery (Example: C/Section, Hysterectomy or D & C)
Current Medications (List dosage and frequency)
Do you smoke cigarettes?    If yes, how many cigarettes per day?
Do you drink alcohol?    If yes, how many drinks per day?
Do you use street drugs?    If so, what drug and how often
Comments or any other significant medical history