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2022 New Patient Medical History Form (Female)

Patient Information

Pharmacy Information

Allergies

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

Medications

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

Gynecological History

Regular/ Irregular/ other comments
Range of days (shortest to longest)
If yes, what method have you used?

Gynecological Review of Systems

You 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 and other helpful details below:

Family Planning History

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

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 Health Maintenance

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

Family History

If you chose any of the previous options, please describe the condition and the family member's relationship to you (example: Maternal grandmother - breast cancer ) :

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:

Past Surgical History

If yes, please describe.
If yes, please describe.

Review of Systems

Check any of the following that you are CURRENTLY experiencing:

Past Medical History

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

Hospitalizations

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

* Required field