Beruflich Dokumente
Kultur Dokumente
Your answers on this form will help your clinician understand your medical concerns and conditions better. If you are
uncomfortable with any question, do not answer it. Best estimates are fine if you cannot remember specific details.
Thank you!
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WOMEN’S GYNECOLOGIC HISTORY:
For Women: # pregnancies:____ # deliveries:____ # abortions: ____ # miscarriages: _____
1st day, most recent period: ______ Age at 1st period:____ Frequency of periods:______ Length of each: _____
Do you have any concerns about your periods? No Yes: __________________________________________
Do you have any concerns about menopause? No Yes: ______________________________________________
FAMILY HISTORY:
Please indicate with a check (√) family members who have had any of the following conditions:
Mom Dad Sist. Bro. Daug. Son Other Mom Dad Sist. Bro. Daug. Son Other
Medical Condition close Medical Condition close
rela- rela-
tives tives
Alcoholism Genetic diseases
Anemia Glaucoma
Anesthesia problem Hay fever (Allergic
Rhinitis)
Arthritis Hearing problems
Asthma Heart Attack (Coronary
Artery Disease)
Birth Defects High Blood Pressure
(Hypertension)
Bleeding problem High cholesterol
(Hyperlipidemia)
Cancer, Breast Kidney diseases
Cancer, Colon Lupus (Systemic Lupus
Erythematosis)
Cancer, Melanoma Mental retardation
Cancer, skin (except Migraine headaches
melanoma)
Cancer, Ovary Mitral Valve
Prolapse
Cancer, Prostate Osteoarthritis
Cancer (not noted) Osteoporosis
Depression Rheumatoid Arthritis
Diabetes, Type 1 Stroke
(childhood onset)
Diabetes, Type 2 (adult Thyroid disorders
onset)
Eczema Tuberculosis
Epilepsy(seizures) Other:
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SOCIOECONOMICS: Are you interested in being screened for sexually transmitted
Occupation: _______________________________ diseases? No Yes
SEXUALITY
Sexual Activity EMOTIONS:
Sexually Active: Yes No Not currently 1. In the past year, have you had 2 weeks or more during which
Current sex partner(s) is/are: male female you felt sad, blue or depressed; or when you lost all interest or
Contraception and Protection pleasure in things that you usually cared about or enjoyed?
Birth Control method:____________________ None needed No Yes
If sexually active, do you practice safe sex? NA No Yes 2. Have you had 2 years or more in your life when you felt
Have you ever had any sexually transmitted diseases (STDs)? depressed or sad most days, even if you felt okay
No Yes sometimes? No Yes
If yes, please include: 3. Have you felt depressed or sad much of he time in the past
_______________________date_______ year? No Yes
_______________________date_______
IMMUNIZATIONS:
Please list your most recent immunizations. You do NOT need to include any immunizations given at Harvard
Vanguard Medical Associates. Please include your best estimate of the month and year of each
immunization:
Hepatitis A ____ Measles ____Mumps____Rubella____ Pneumovax (Pneumonia)____
Hepatitis B ____ MMR____
Tetanus (Td) ____ Varicella (chicken pox) shot ____ Other ____
REVIEW OF SYSTEMS: Please check (√) any current problems you have on the list below.
Constitutional Chest (breast) Skin
___Fevers/chills/sweats ___Breast lump/discharge ___ Rash or mole change
___Unexplained weight loss/gain Respiratory Neurological
___Fatigue/weakness ___Cough/wheeze ___Headaches
___Excessive thirst or urination ___Difficulty breathing ___Dizziness/light-headedness
Eyes Gastrointestinal ___Numbness
___Change in vision ___Abdominal pain ___Memory loss
Ears/Nose/Throat/Mouth ___Blood in bowel movement ___Loss of coordination
___Difficult hearing/ringing in ___Nausea/vomiting/diarrhea Psychiatric
ears Genitourinary ___Anxiety/stress
___Problems with teeth/gums ___Nighttime urination ___Problems with sleep
___Hay fever/allergies ___Leaking urine ___Depression
Cardiovascular ___Unusual vaginal bleeding Blood/Lymphatic
___Chest pain/discomfort ___Discharge: penis or vagina ___Unexplained lumps
___Leg pain with exercise ___Sexual function problems ___Easy bruising/bleeding
___Palpitations Musculo-skeletal Other (please specify)_______
AB 11/29/03 ___Muscle/joint pain ________________________
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