PLANNED PARENTHOOD OF GREATER NORTHERN NJ

INITIAL VISIT MEDICAL RECORD

(ASSURANCE OF CONFIDENTIALITY: This medical record is confidential and will not
be released to anyone without your written consent except as may be required by law.)

PLEASE PRINT Date: Sex: F… M…

Name:
Last First M.I.
Has your name changed: … No … Yes Previous name:
… Single … Married … Widowed … Divorced
Address:
Street Apt. # City State Zip
Date of Birth:_____/_____/_____ Age: SS#:
(M / D / Y)
Check ALL the ways we may contact you
… Call Home: phone #:________________________________________________________
… Call Beeper/cell phone #:______________________________ Best Time:___________
… Call Work: phone #:________________________________________________________
… Call Other:__________________________________________ Best Time:___________
Can we identify ourselves as Planned Parenthood
If we call you: … No … Yes If we write you: … No … Yes
… Coded Contact What should we say:

EMERGENCY CONTACT PERSON (Legal Guardian, if under 18)

Name: Relationship:____________________________________
Address: Phone:____________________________

REASON FOR VISIT

I am here today because:

Other medical providers seen in the last year:

YOUR HEALTH/WELLNESS LIFESTYLE

Do you or have you ever smoked: … No … Yes Age started:_______ Number per day:_______
Quit Date:___________

Do you or have you ever consumed alcohol: … No … Yes Age started:____ # drinks at one time:_____ # of drinks per
wk:_____
When was the last time you had more than 4-5 drinks in one day: … Never … In the past 3 months … Over 3 months ago

What social/street drugs have you used:_______________________________________________________

How often:__________________________ Date last used:____________________________

Do you exercise: … No … Yes Times/week: _____Minutes/day:______

Do you wear: A seat belt in the car … No … Yes Helmet on a bike, skateboard or skates … No … Yes

Are there any personal or religious preferences that might affect your health care (for example, no blood products):
… No … Yes Describe:

HAVE YOU EVER USED IV DRUGS: … No … Yes Have you ever had sex with an intravenous drug user:
… No … Yes … Unknown
Patient Name:
Date: _____/_____/_____ Patient Number: ___________________
Date of Birth:____________________________
PPGNNJ 11/09 Confidential property of Planned Parenthood of Greater Northern NJ, Inc. Initial Visit Medical Record MSG 12.6.3 English only

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 YOUR SEXUAL HISTORY
Are you currently sexually active: … No … Yes Age at first intercourse:_____________
Number of new sex partners within the past 3 months:________
More than one sexual partner in the last 12 months: … No … Yes
Has your partner had more than one sexual partner in the last 12 months: … No … Yes … Unknown
Partners have been: … Male … Female … Both Sites of sexual contact: … oral … vaginal … anal
Does your partner have a history of sex with the same gender: … No … Yes … Unknown
Have any of your partners ever been treated for a sexually transmitted disease: … No … Yes … Unknown
Have you ever been physically or sexually abused or raped: … No … Yes Date:________________
Was it reported: … No … Yes Did you receive counseling: … No … Yes

STD HISTORY
Have you ever had DATE: TREATED: DATE: TREATED:
HPV/Warts: ________ ________ Gonorrhea: ________ ________
Scabies: ________ ________ Chlamydia: ________ ________
PID: ________ ________ Molloscum: ________ ________
Trich: ________ ________ Vaginal infections: ________ ________
Herpes: ________ ________ Syphilis: ________ ________

Do you use condoms: … No … Yes … Sometimes … Always

PLEASE ANSWER ALL QUESTIONS (Please Circle)

IF MALE please answer
1. History of Penile discharge: Y N 5. Do you examine your Y N 8. Premature ejaculation: Y N
Describe: testes:

2. Hernias Y N 6. Pain in testes/scrotum: Y N 9. Sexual dysfunction/ Y N

impotence:
3. Prostate problems: Y N

4. Have you ever had a P.S.A.: Y N 7. Mass/lump in testes/ Y N 10. Lesions or bumps: Y N
scrotum: How long:

IF FEMALE please answer

CONTRACEPTIVE HISTORY

Method today: Sex without contraception (including condom accident) in the last 5 days: … No … Yes

Prior methods: DATE: REASON STOPPED:

… Pills: ___________________________________________
… Patch: ___________________________________________
… Nuvaring: ___________________________________________
… IUC: ___________________________________________
… Injections: ___________________________________________
… Monthly: ___________________________________________
… Every 3 months: ___________________________________________
… Implants: ___________________________________________
… Condoms: ___________________________________________
… Diaphragm/Cap: ___________________________________________
… Natural Family Planning: ___________ ___________________________________________
Patient Name:
Date: _____/_____/_____ Patient Number:
Date of Birth:
PPGNNJ 11/09 Confidential property of Planned Parenthood of Greater Northern NJ, Inc. Initial Visit Medical Record MSG 12.6.3 English only

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 IF FEMALE please answer (cont.)

A. Menstrual history: Age of Age: H. Abnormal uterus Y N O. Any problems in past Y N

onset: Describe: Pregnancies
Describe:

B. Are periods regular: Y N I. History of Vaginal Discharge: Y N P. Are you currently Y N

Heavy/moderate/light: H M L Describe: Breastfeeding:

C. Periods are every: __________ J. Lesions or bumps Y N Q. Last mammogram: Date

Days and last:_________ How long:
days

D. Last pelvic exam: Date K. Have you ever tried to get Y N R. Sexual dysfunction Y N
pregnant and couldn’t: Describe:

E. Last PAP: Date L. Do you desire pregnancy in Y N S. Intercourse: Do you have Y N

the future (WHEN): pain and/or bleeding:

F. Abnormal PAP: Describe: Y N M. Total number of pregnancies: #:

G. Prior colposcopy/cryo/LEEP/ Y N N. Date last pregnancy ended, Date

laser/cone: Describe: regardless of outcome:

Patient Name:

Date: _____/_____/_____ Patient Number:

Date of Birth:
PPGNNJ 11/09 Confidential property of Planned Parenthood of Greater Northern NJ, Inc. Initial Visit Medical Record MSG 12.6.3 English only

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 A. REVIEW OF SYSTEMS: 29. Osteoporosis? D. FAMILY HISTORY
Yes
N
GENERAL 30. SLE (lupus)? Are you adopted? ‰ Yes ‰ No
O
SKIN Have your biological family (parents, brothers, sisters)
1. Is your health generally good? had any of the following?
2. Unexplained weight loss or gain of more 31. Breast Lump/Discharge? Yes
N
Diagnosis Relative
O
than 10 lbs. in the past year? 32. † Tattoo? †Piercing? If yes, where? -
Osteoporosis?
3. Night sweats/hot flashes? _________________
Diabetes?
4. Are you being treated for any illness/ NEUROLOGICAL
Heart disease/heart attack/
condition now? If yes what?
stroke before age 50?
5. Physical/Emotional Abuse? 33. Headaches?
6. Coercion/Rape/Incest? High blood cholesterol?
34. Migraine headaches /Aura (diagnosed by
7. Have you been hit, kicked, punched or MD/NP/PA)? Genetic problems?
otherwise hurt by someone in the past year? 35. Seizures/epilepsy? Cancer? If yes, please specify
8. Do you feel safe in your current _________________________
36. Numbness in arms/legs (recurring)?
relationship? Blood clots?
PSYCHOLOGICAL
9. Is there a partner from a previous Other?
relationship who is making you feel unsafe 37. Depression requiring treatment? Have
now? you ever considered suicide? † Yes † No If you were born before 1972, did your mother take DES
10. Hearing problems? NO YES UNKNOWN
38. Other psychological problems?
11. Frequent nosebleeds? ENDOCRINE
Allergies to: Medications, LATEX, Environment, Food,
CARDIO-RESPIRATORY
Other?
39. Thyroid problems?
12. Heart disease? 40. Diabetes?
Medications: Including Prescription, over-the-counter,
13. Varicose veins? HEMATOLOGICAL/LYMPHATIC
herbals and vitamins:
14. Blood clots (head/leg/lungs)? 41. Anemia (Low Iron)?
15. Stroke or stroke-like problems? 42. Sickle cell disease/trait?
16. High blood pressure? 43. Blood clotting disorder? Current: Past 12 Months:
17. High cholesterol? 44. Transfusion of blood/blood products?
18. Chronic cough or other breathing IMMUNOLOGIC
problems/asthma? 45. HIV/AIDS?
19. Tuberculosis or exposure to tuberculosis? 46. Cancer?
GASTROINTESTINAL IMMUNIZATION (Check the ones you have received)
47. ‰ Hepatitis A?
To the best of my knowledge, the above information is
20. Stomach or bowel problems? 48. Hepatitis B ‰ shot 1? ‰ shot 2? ‰ shot 3?
complete and accurate.
21. Liver problems (hepatitis or tumor, etc.)? 49. Human Papillomavirus (HPV) ‰ shot 1? ‰ shot 2?
22. Gallbladder problems? ‰ shot 3?
Signature of Patient:
23. Rectal Bleeding/pain/itching? 50. ‰ Measles/Mumps/Rubella (MMR)?
GENITOURINARY B. HOSPITALIZATION AND SURGERIES
Year Reason Signature of Interpreter:_______________________
24. Bladder, urine leakage or kidney problems
Printed Name of Interpreter:____________________
25. Pain, burning or frequent urination?
26. Frequent bedtime urination? Date: _____/_____/_____
27. Incontinence? C. ACCIDENTS AND INJURIES Patient Name:
MUSCULOSKELETAL/RHEUMATOLOGICAL Year Reason
Patient Number:
Date of Birth:
28. Arthritis?
PPGNNJ 11/09 Confidential property of Planned Parenthood of Greater Northern NJ, Inc. Initial Visit Medical Record MSG 12.6.3 English only

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