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New Patient Medical History Form (Female)

Patient Information

Pharmacy Information

Past Medical History

If you have selected any of the previous boxes, enter details below:

Past Surgical History

Hospitalizations

If you have been hospitalized for any reason (excluding surgeries listed above and deliveries), please describe here:

Medications

Please list your current medications, including vitamins and herbs, and their respective doses:

Allergies

Please list any allergies to medications (or latex) that you may have:

Pregnancy History

Date, gender, type of delivery, birth weight, weeks at birth, fertility treatments, time to conceive for each pregnancy. Please include miscarriages, abortions, ectopic pregnancies, etc.

Gynecological History

Regular/ Irregular/ other comments
Range of days (shortest to longest)
If yes, please describe.
If yes, please describe.

Family Planning History

For above, please add details(dates of use, types or names) below:

Family History

If you chose any of the previous options, please describe the condition and the family member's relationship to you:

Social History

type, servings/day
type, servings/day

Have you used any of the following:

If yes, servings/day and type
If yes, how much, or how many packs per day, and how many years have you been smoking?
If checked, please describe below:

Health Maintenance

For each option chosen above, please enter the date each test was taken and its result below:

Review of Systems

Check any of the following that you are CURRENTLY experiencing:

Gynecological Review of Systems

If yes, what method have you used?
Can describe abnormal bleeding here.
If other describe below:
Please describe below:

Prior Fertility Testing

Describe tests, dates, and results below:
Please give number of cycles of all treatments other helpful details below:
* Required field