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Patient History Form ALL INFORMATION IS STRICTLY CONFIDENTIAL Please provide the following information and click the "Submit Form" button. The fields marked with an asterisk (*) are required. Patient Information First Name* Middle Name/Initial Last Name* Address Line 1* Address Line 2 Address Line 3 City* State* Select Below Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Other ZIP* USA Date of Birth (MM/DD/YYYY)* Age* Race Occupation Daytime Phone* Evening Phone Cell Phone Pager Email Address Fax If we need to call you, may we identify ourselves as "Doctor's Office" to whomever answers?* YES NO If "NO", please give a phone number where we can leave a message Name of Family Physician How did you learn about us? Medical History Do you smoke cigarettes? YES NO If "YES", how many per day? How many Years? Do you have any Allergies? YES NO If "YES", please list/explain below: Have you ever had a reaction to Anesthesia or Lidocaine? YES NO Are you currently taking any prescription or over-the-counter medications? YES NO If "YES", please list below: Do you use street drugs? YES NO If "YES", please list below: Are you currently in a drug treatment program? YES NO If "YES", please list below: Family History Are you adopted? YES NO Has anyone in your family ever had: Cancer Diabetes High Cholesterol Heart Attack Stroke High Blood Pressure Hereditary Disease Check any of the following you have had: Frequent Headaches Diagnosed Migraines Double Vision Thyroid Problem Heart Problem/Murmer Rheumatic Fever Tuberculosis Chest Pain Shortness of Breath Asthma Breast Lump/Discharge Stomach or Bowel Problems Hepatitis/Liver Disease Gall Bladder Disease Surgery of Reproductive       Organs Vaginal Infection Sexually Transmitted       Diseases Abnormal PAP Report High Cholesterol Stroke High Blood Pressure Hiatal Hernia Sleep Apnea Bladder/Kidney Infections Leg Cramps Varicose Veins Blood Transfusion Blood Clot/Phlebitis Bleeding Disorder Circulatory Problem Swollen Ankles/Feet Anemia/Low Iron Epilepsy/Seizures Fainting Spells Diabetes Sickle Cell Disease/Trait Cancer Surgery RH Negative Blood Factor Mononucleosis Severe Mood       Change/Depression Please list any others below: Menstrual History First Day of Last Normal Period Was your Last Period On Time Late Early Shorter Lighter Heavier Spotting Normal Other Contraceptive History Have you ever used any of the following birth control methods? Pill DEPO (Injection) Lunelle (Injection) Condom Spermicide IUD Diaphragm Ortho Evra Other Problems with any of the above methods: Were you using birth control when you became pregnant? YES NO Do you desire birth control after your surgery today? YES NO What method would you like to use? Pregnancy History How many times have you been pregnant? (include present pregnancy) How many were: Live Births Still Births Cesarean (C-Section) Multiple Births Miscarriages Abortions Complications (check all that apply): Toxemia Premature Labor RH Problems Ectopic/Tubal Pregnancy Gestational Diabetes Other Sexual History (Optional) Age at first intercourse: Any pain with intercourse? YES NO Number of sexual partners in the past year: Other (Optional) Other Special Instructions or Comments About Us | Fact Sheets | Common Questions | Forms | Service Fees Appointments | Employment | Directions | Contact Us | Main Page Copyright © 2001 Reproductive Health Services, Inc. All Rights Reserved. This site designed by CyberLink, LLC. Visit Website at www.cyber-link.net