Rittenhouse Women's Wellness Center

Health History Form

Name Sex Date of Birth Date of Last Physical Exam

Personal Health History

Childhood Illness Immunizations and Date Please list dates for each of the above vaccines that you have received List any medical problems that other doctors have diagnosed: Surgeries Other Hospitalizations Have you ever had a blood transfusion? List your prescribed drugs, and over-the-counter drugs, such as vitamins and inhalers Allergies to Medications

OB/GYN

Age at onset of menstruation Date of last menstruation Period every how many days? Heavy periods, irregularity, spotting, pain, or discharge? Number of pregnancies/Number of live births Are you pregnant or breastfeeding? Have you ever had a D&C, hysterectomy, or Cesarean? Any urinary tract, bladder, or kidney infections within the last year? Any blood in your urine? Any problems with control of urination? Any hot flashes or sweating at night? Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around the time of your period? Experienced any recent breast tenderness, lumps, or nipple discharge? Date of last pap and pelvic exam? Have you had an abnormal pap smear?

Other Problems

Check if you have had any symptoms in the following areas to a significant degree: If you checked any boxes above, please explain:

Family Health History

For each family member below, please list age (or age at death) and any significant health problems and/or cause of death

Mother Father Siblings Children Grandmother (maternal) Grandfather (maternal) Grandmother (paternal) Grandfather (paternal) Do you have any family members with:

Mental Health

Is stress a major problem for you? Do you feel depressed? Do you panic when stressed? Do you have problems with eating or your appetite? Do you cry frequently? Have you ever thought seriously about hurting yourself? Do you have trouble sleeping? Have you ever been to a counselor?

Health Habits and Personal Safety

Exercise Alcohol - Do you drink alcohol? If yes, what kind? How many drinks per week? Are you concerned about how much you drink? Have you considered stopping? Have you ever experienced blackouts? Are you prone to "binge" drinking? Do you drive after drinking? Tobacco - Do you use tobacco? Type of tobacco: How many packs/chews/pipes/cigars per day Drugs- Do you currently use recreational or street drugs? Have you ever given yourself street drugs with a needle? Sex - Are you sexually active? If yes, are you trying for pregnancy If not trying for pregnancy, please list contraceptive or barrier used: Any discomfort with intercourse? Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors include intravenous drug use and and unprotected sexual intercourse. Would you like to speak with your provider about your risk of this illness? Personal Safety - Do you live alone? Do you have frequent falls? Do you have vision or hearing loss? Do you have an Advance Directive or Living Will? Physical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discuss this issue with your provider?