Annual History Form

Name:  ___________________________________________       Age: ___________     Date:  __________________________

Marital Status:  _________   Occupation:  _______________________________   First day of your last period:  _______________

I.    List any problems or concerns you are having:  __________________________________________________________________

      _________________________________________________________________________________________________________

      _________________________________________________________________________________________________________

II.   List other physicians you have seen since your last visit.  [] None

      Name of doctor                                               Date                 Problem

      ____________________________          ___________      _______________________________________________________

      ____________________________          ___________      _______________________________________________________

      ____________________________          ___________      _______________________________________________________

III. Surgeries or hospitalization since your last visit.  []  None

      Type of surgery or reason for hospitalization           Date                   Doctor             Name of Facility

      __________________________________    ________        ___________   _________________________________________

      __________________________________    ________        ___________   _________________________________________

IV  (A) Current contraception:  [] None  [] Vasectomy  [] Tubal Ligation  [] Hysterectomy  [] IUD  [] Condoms 

            [] Diaphragm  [] Depo-Provera  [] Implanon  [] Pills:  Brand _________________     [] Other _______________

      (B) Number of sexual partners in last year _________     [] male [] female [] both

      (C) Current medications and dosage:  [] None  ______________________________________________________________________

      _________________________________________________________________________________________________________

      _________________________________________________________________________________________________________

      (D) Medication Allergies:  []  None  ______________________________________________________________________________

V.  Since your last visit, have you had a problem with:

                                                Yes No                                                            Yes  No                 

      1.Abnormal periods                 []    []                11.Black or bloody stools         []    []          

      2.Bleeding between periods     []    []                12.Change in bowel habits       []    []         

      3.Bleeding after intercourse     []    []                13.Frequent urinary infections  []    []         

      4.Severe pain with periods       []    []                14.Blood in urine                     []    [] 

      5.Breast mass or lumps            []    []                15.Leakage of urine                []    []   

      6.Breast secretions                  []    []                16.Crushing chest pain             []    [] 

      7.Blood from nipples                []    []                17.Palpitations                         []    [] 

      8.Heat or cold intolerance        []    []                18.Shortness of breath at rest   []    []

      9.Extreme fatigue                    []    []                19.Change in headaches          []    []

     10.Change in skin mole             []    []                20.Severe depression               []    []

VI. Do you:

                                              Yes No                                                             Yes  No

      Exercise regularly              []    []                      Use recreational drugs          []    []

      Do monthly breast exams   []    []                      Smoke                                 []    []

      Have questions about domestic                          Drink alcohol                       []    []

              or sexual abuse          []    []                           Amount  _____________________

      Wear seatbelts                   []    []                   Wear helmets when you bike   []    []         

VII.  When was your last cholesterol?  _______________       Where?  _______________

      When was your last mammogram?  ______________        Where?  _______________

      When was your last colonoscopy?  _______________        Where?  _______________

      When was your last tetanus?  __________________

VIII. Family history:                                                                                            Yes  No

1.         Since your last visit, have there been any deaths in your family?                  []      []   

2.         Since your last visit, has there been any significant illness in the family?       []      []         

3.         Family history of cancer of the []breast []ovary []uterus []cervix []colon?    []      []         

4.         Family history of   [] osteoporosis  [] diabetes  [] heart attacks

                                 [] high cholesterol  [] Alzheimer’s  [] thyroid disease              []      []

Information on this website is for educational and reference purposes only and should not be interpreted as specific medical advice.

Copyright © 2009

Women Physicians

Ob-Gyn Medical Group

650.988.7550