700 Gervais Street, Suite 300, Columbia, SC 29201

Ph: (803) 254-3230 • Fx: (803) 540-1180

A Lexington Medical Center Physician Practice VistaWomens.com

Patient History Form

Primary Care Physician: Referring Physician:

Marital Status: Single Married Separated Widow Divorced

Reason for visit:

Gynecological History
Age period began: Date of last menses: Are menses regular? Yes No
Number of days between menses: Number of days bleeding: Do you have pain with periods?
Are you sexually active? Yes No heterosexual homosexual bi-sexual Yes No

Current Birth Control Method: What other methods have you used Heavy flow/clots?
in the past? Yes No
Have you ever been diagnosed with an STD? What? Have you been tested for HIV (AIDS)?
Yes No When? Results: Positive Negative
Date of last pap: Results: Normal Abnormal
Have you ever had an abnormal smear? Yes No How was it treated?
Date of last mammogram: Results: Normal Abnormal
Date of last colon cancer screening: Date of last bone density study:
Have you had recent blood work to check cholesterol, glucose, and thyroid? Yes No
Have you had any of the following vaccines in the past 10 years? Shingles vaccine HPV vaccine Tetanus/diphtheria vaccine Hepatitis B

Obstetric History
Total number of pregnancies: _______ Miscarriage: _______ Abortions: _______ Living Children: _______
Any complications of pregnancy or delivery?
Did you have gestational diabetes? Yes No Hypertension? Yes No Preeclampsia? Yes No

No. Birth Date Male/Female Birth Weight Type of Delivery No. Birth Date Male/Female Birth Weight Type of Delivery
1 4
2 5
3 6

Current Medications (Also include all vitamins, herbs, and any frequently used over-the-counter medications)
Drug Name: Dosage: Prescribed by: Drug Name: Dosage: Proscribed by:

 Attached Medication List

Do you have a latex allergy? Yes No

Medical History
Illness Date Illness Date

Surgical History
Surgery Date Surgery Date

Social History
Do you smoke? Yes No How much? How many years?
Do you drink alcohol? Yes No How many drinks in a week?
Do you use street drugs? Yes No What type and how often?
Any history of sexual or physical abuse? Yes No What is your current occupation?

Family History
Father: Living Deceased Cause of death: Age of death:
Mother: Living Deceased Cause of death: Age of death:
Family history unknown
Is there a family history of the following? (Please list affected family members)
Diabetes Stroke
Hypertension Heart disease
High Cholesterol Blood clots in legs/lungs
Osteoporosis Breast cancer
Colon cancer Ovarian cancer
Uterine cancer Mental illness/depression
Thyroid Endometriosis
Fibroids

Review of systems (Please check yes if you are currently experiencing the symptoms below)
Symptom Symptom Symptom
Weight loss/gain Yes No Irregular heartbeat Yes No Fatigue Yes No
Constipation/diarrhea Yes No Visual problems Yes No Urinary leakage Yes No
Chest pain Yes No Frequent urination Yes No Difficulty breathing Yes No
Painful urination Yes No Joint/muscle pain Yes No Frequent headaches Yes No
Breast pain Yes No Depression/anxiety Yes No Breast discharge Yes No
Hot flashes Yes No Abnormal thirst Yes No Hair loss Yes No