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Allergies to medications/food/environment

Desert West Obstetrics and Gynecology, Ltd. Name ________________________________ Birthdate_________ Age _____ Date____________ Allergies to medications/food/environment
Reaction
Current Medications
Instructions
Reason Used
(Prescription, over the counter, herbal) Prescribing Doctor
What do you do so you don't become pregnant? ____ Diaphragm ____ Other ___________________________________________________________________ First day of last period_________________________________ What age were you when you started your first period? ______________ Are your periods regular? ____________________ Is there bleeding between periods? ____________ How often do your cycles occur? ___________________________ For how many days do you bleed? __________________________ Flow is: ______ scant ______ mild ______ mod ______ severe ______ incapacitating Other symptoms with periods? ______________________________________________________________ _______________________________________________________________________________________ Date of last pap smear ___________________________________ How? ________________________________________________________________________ When was your last Mammogram (if any)? ___________________ Result ___________________________ Do you have concerns about your breasts? ____________________________________________________ When was your last Bone Density (if any)? ___________________ Result ___________________________ Past Medical / Surgical History(Include injuries and conditions requiring
medication -i.e. -high blood pressure, seizures, diabetes, etc)
Condition/Disease
Treatment
Desert West Obstetrics and Gynecology, Ltd. Name ________________________________ Birthdate_________ Age _____ Date____________ Have you had: Total number of pregnancies
Cesarean
Premature
Delivery
Miscarriage
Abortion
Stillborn
Pregnancy Details
Number of
Delivery Obstetrical/Neonatal
Problems
Delivery Doctor
Family History
Please complete if any of your close relatives have had any of the following: Family Members 1st
Cause of Death
Family Member
(Circle)
Desert West Obstetrics and Gynecology, Ltd. Name ________________________________ Birthdate_________ Age _____ Date____________
Social History
Primary Language Spoken____________________________________
Do you smoke? No_____ Yes_____ If yes, type of tobacco?_______________ Number of years_____ Pks/day_____ Do you drink alcohol? No_____ Yes_____ If yes, type of alcohol____________________________________________ How often?__________________________ Amount______________________ Last drink________________________ Do you consume caffeine? No_____ Yes_____ If yes, what kind?_______________ Amount_____________________ Do you use recreational drugs? No_____ Yes_____ If yes, what kind?_______________________________________ Exercise frequency? Daily_____ Never_____ Occasional_____ 2-3times/wk_____ 4 or more times/wk_____ How many sexual partners do you have? None_____ One_____ 2-5_____ 5+_____ Have you been exposed to sexual or physical violence or abuse? Are there animals in the home? No_____ Yes_____ If yes, what kind?_______________________________________ Is the patient the individual who cleans up after the animals? If medically necessary, would you agree to a transfusion? REVIEW OF SYSTEMS
If you are experiencing any of the symptoms listed, PLEASE CIRCLE THE ONES THAT APPLY, or write NONE.
Constitutional (Health in General): Fatigue, fever, night sweats
Ears, Nose, Mouth and Throat: Eye discharge, vision loss, ear drainage, hearing loss, nasal drainage

Respiratory: Cough, wheezing, difficulty breathing or shortness of breath
Cardiovascular: Chest pain, irregular heartbeat, palpitations
Gastrointestinal: Abdominal pain, constipation, diarrhea, vomiting
Genitourinary: Painful periods, pain with urination, blood in urine, excessive menstrual bleeding, vaginal discharge
Neurologic/Psychiatric: Walking or balance difficulties, depression, anxiety, mood swings
Dermatologic: Skin itching, rash
Musculoskeletal: Bone weakness, joint weakness
Hematology: Easy bleeding, easy bruising
Immunology: Environmental allergies, food allergies

Source: http://desertwestobgyn.com/documents/confidential_medical_history.pdf