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PATIENT HISTORY
Name: Date of Birth:
PAST MEDICAL HISTORY:
Have you ever been diagnosed with any of the following?
Cancer: ____ Yes ____No ____ Yes ____No What kind:_____________________________________ When?_______________________ What kind:_____________________________________ When?_______________________ What kind:_____________________________________ When? ______________________
Medical Record Number:
Revised 7/31/19 1 of 4
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PATIENT HISTORYOBSTETRICS AND GYNECOLOGY HISTORY:
Last Menstrual Period: _________________ Are you sexually active? _____Yes _____No Please specify, if any, irregularities about your period: ____________________________________________________________________________________ Child Birth: __________________________________________________________________________ Abortions, miscarriages, stillbirths, C-sections: ______________________________________________
WHAT OTHER PROVIDERS DO YOU SEE? or HAVE YOU SEEN IN THE PAST?
Have you ever had any of the following operations? If so, when?
Appendectomy (Appendix) _____Yes _____No __________ Date / Year Tonsillectomy (Tonsil Removal) _____Yes _____No __________ Date / Year Cholecystectomy (Gallbladder) _____Yes _____No __________ Date / Year Hysterectomy (Uterus) _____Yes _____No __________ Date / Year Mastectomy (Breast Single or Bilateral) _____Yes _____No __________ Date / Year Bypass Surgery (Heart) _____Yes _____No __________ Date / Year Cataract Laser _____Yes _____No __________ Date / Year Hemorrhoidectomy (Hemorrhoids) _____Yes _____No __________ Date / Year Colectomy (Colon Removal) _____Yes _____No __________ Date / Year Hernia Repair _____Yes _____No __________ Date / Year Anesthesia Complications _____Yes _____No __________ Date / Year