Name ________________________________________ Birthdate _____________ Today’s Date _________

School ___________________________   Reason for today’s visit __________________________________

Have you had: (please check)

£ Acne                               £ Allergies/Hayfever             £ Anemia                 £ Asthma

£ Bladder/Kidney Infection       £ Blood disorder                  £ Blood Transfusion    £ Cancer

£ Chicken Pox                   £ Depression                        £ Diabetes                £ Eating Disorder

£ Emotional Disorder         £ Epilepsy/Seizure Disorder       £ Learning Disability       £ Headaches

£ Heart Disease                 £ Hepatitis                                  £ Pneumonia               £ Rheumatic Fever

£ Scoliosis                               £ Stomach Problems             £ Thyroid Disease       £ Tuberculosis

£ Other _______________________________________________________________________

Immunizations: (please indicate date of last dose)

Hepatitis A ____________Hepatitis B ________________ Rubella ___________Meningococcus ________

Tetanus _____________Varicella (Chicken Pox) __________HPV Vaccine (Cervical Cancer) ___________

Menstrual Periods:

Age at 1^st period ___________ First day of last period ____________ Duration of flow ________________

How often do you have periods?________________________________ Do you have cramps?   Yes   No

Do you take medications for cramps?    Yes   No      Name of medication ____________________________

Personal History:

Surgeries ____________________________________________________________________________

Hospitalizations _______________________________________________________________________

Serious Injuries ________________________________________________________________________

Allergies to Medications __________________________________________________________________

Current Medications ____________________________________________________________________

Over-the-Counter Medications ____________________________________________________________

Herbs & Vitamins ______________________________________________________________________

Family History:

                 Yes  No  Don’t Know  (if yes, list who)                                       Yes  No  Don’t Know (if yes, list who)

Blood Clots []   []   []  ________________________          Blood Disorders []   []   []  ____________________

Cancer         []   []   []  ________________________          Depression         []   []   []  ___________________

Diabetes       []   []   []  ________________________          Heart Disease     []   []   []  ___________________

Stroke          []   []   []  ________________________          High Cholesterol []   []   []  ___________________

Other _______________________________________________________________________________________