Patient History Form by s90P2am8

VIEWS: 7 PAGES: 6

									                                 OB/GYN, LTD
                             1108 VESTER AVENUE
                           SPRINGFIELD, OHIO 45503
                              PHONE (937) 399-7100

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      Name _______________________ Date of Birth __________ Age ___________

      Marital Status: S ________ M ______ Height ______ Weight ______________

      Address __________________ City _____________ State ____ Zip Code _____

      Home Phone ____________ Cellular Phone ___________ Work Phone _______

      Occupation ___________________ Employer ___________________________

      Referred by ____________________________________________________

      Notify in an Emergency _____________________________ Relationship ______

      Emergency Contact Home Phone _____________ Cell Phone _______________

      Address __________________________________________________________

CC: What are your present symptoms or problems?______________________________

      __________________________________________________________________

PMHX: Do you have any medical conditions? If so, describe _____________________

      _________________________________________________________________

      Have you had any operations? Describe (list dates and type of anesthesia) ______
      _________________________________________________________________

      Any past problems with anesthesia? If so, describe ________________________

      __________________________________________________________________

      Any bleeding problems? Describe ______________________________________

      __________________________________________________________________

      Any reaction to local anesthetic (novocaine)? Describe _____________________
       Have you ever had: Hepatitis ____ Aids (HIV) ____ Blood transfusion ____
                     Blood clots in the lungs or the legs _______

Meds: List your current medications and dosages (include over the counter medications
you take) ________________________________________________________________

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Allergies: Do you have any allergies? List ____________________________________

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Family History: Please describe any medical problems in your family:

       Mother: ___________________________________________________________

       Father: ___________________________________________________________

       Siblings: __________________________________________________________

Social History: Do you smoke? _____ How much? _______ What? ________________

       Do you drink beer/alcohol? _________ How much and how often ____________

       Do you use any medications or drugs not prescribed by a doctor? If so, list _____

       _________________________________________________________________

Is there anything else you would like us to know about your condition? ______________

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Do you have headaches?                           Yes _____    No _____
Do you have trouble with your vision?            Yes _____    No _____
Have you ever had seizures?                      Yes _____    No _____
Do you have weakness or numbness in your
       arms or legs?                             Yes _____    No _____
Do you have a cough?                             Yes _____    No _____
Do you have trouble breathing?                   Yes _____    No _____
Do you have any pains in your chest?             Yes _____    No _____
Do you have any trouble swallowing?              Yes _____    No _____
Do you have heartburn?                           Yes _____    No _____
Do you have any pains in your stomach?           Yes _____    No _____
Have you lost any weight in the last 2 months?   Yes _____    No _____
Do you have diarrhea or constipation?            Yes _____    No _____
Any blood in your stool?                         Yes _____    No _____
Have you had nausea or vomiting?                 Yes _____    No _____
Any trouble passing urine?                       Yes _____    No _____
Do you have menstrual periods?                   Yes _____    No _____
Date of last menstrual period __________________
Do you take birth control pills?                 Yes _____    No _____
Date of last pelvic exam/pap smear _____________
Have you ever been pregnant?                     Yes _____    No _____
How many children ? ________________________
Do you have any breast problems?                 Yes _____    No _____
Do you feel sad, blue, unhappy or “down in
       the dumps”?                               Yes _____    No _____
Do you feel tired, having little energy,
       unable to concentrate?                    Yes _____    No _____
Do you have trouble sleeping or eating
       (too little or too much) ?                Yes _____    No _____
Do you leak urine when you do not want to?       Yes _____    No _____

Do you have any other complaints? ___________________________________________

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Is there anything else you would like to discuss? ________________________________

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Signature X _______________________________________ Date __________________



                   DOCTORS USE ONLY – DO NOT FILL IN
                                 OB/GYN HISTORY

Presenting complaint: ______________________________________________________

________________________________________________________________________

________________________________________________________________________

Workup to date: (X-rays, office procedures, consults, ultrasounds, etc.) ______________

________________________________________________________________________

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Last Pelvic: ____________ Pap: _______________ Results: _____________________
               (date)            (date)

LNMP: ___________ EDC: ________ Menses: _______ ________ _______ L M H
                                        (age at    (cycle) (duration) (flow)
                                         onset)
Amenorrhea __________________ IMB: ______________ PCB: _________________
             (months)
Dysmenorrhea ________________________ Dyspareunia ________________________
              (months/years)                        (months/years)

STD Type and Treatment: __________________________________________________

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Vaginitis: __________ Describe: ____________________________________________

Contraception: _______________ Type: ________________ How Long: ____________

Problems: _______________________________________________________________

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Pregnancies: ___ Term: ___ Premie: ___ Spont. AB: ___ Therap. AB: ___ Living: ___

Last Live Birth: ___________ Largest Baby: __________ Lbs. _______ Oz. _________

Last Pregnancy : ____________________ Complications: ________________________

Birth Defects: ____________________________________________________________

                 FOR DOCTORS USE ONLY – DO NOT FILL IN
                                  PHYSICAL EXAM

Mark with an asterisk (*) abnormal findings only. Check mark or absence mark indicates
normal findings. Examinations not done, indicate by designation ND.

Date __________ Height _____ Weight _____ T ____ P ____ BP _____________

General:

Head:                                 Neck:                         Chest:

   Eyes                               Glands                        Heart

   Ears                               Thyroid                       Lungs

   Nose

   Throat

Breasts:

   Size                               Symmetry

   Scars                              Discharge

   Contour                            Masses

   Nipples

Back:                Extremities:              Joints:       Neurological:

   Spine               Varicosities

   CVA                 Edema

Abdomen:

   Contour           Symmetry                  Panniculus           Scars

   Hernia            Spasm                     Tenderness           Rebound

   Masses            Distention                Peristalsis          Liver

                     Spleen                    Kidneys              Bladder

                 FOR DOCTORS USE ONLY – DO NOT FILL IN
Pelvic

         EFG _____________________________________________________________

         _________________________________________________________________

         Vag _____________________________________________________________

         _________________________________________________________________

         Cervix ___________________________________________________________

         _________________________________________________________________

         Bimanual _________________________________________________________

         _________________________________________________________________

         Rectal ____________________________________________________________

         __________________________________________________________________

Impression: ______________________________________________________________

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Plan: ___________________________________________________________________

________________________________________________________________________

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Comments: ______________________________________________________________

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                             X ____________________________________________

								
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