Ngcsu student health services

STUDENT HEALTH SERVICES MEDICAL HISTORY
NAME:_____________________________________ ID:_______________ DOB:_______________DATE:_______________
ADDRESS:___________________________________________________________________UNG BOX #_____________
CITY, STATE, ZIP ______________________________________________________________________________________
How would you like to be contacted for results of tests sent out to the reference lab? (please circle)
Home address or Box number or Phone number--if phone number, please provide number:_______________________
In case of emergency contact:
NAME:___________________________________ PHONE:____________________ RELATIONSHIP:___________________
NAME:___________________________________ PHONE:____________________ RELATIONSHIP:___________________
When was your last menstrual cycle? ____________________________ Was it normal?_____________________
When was you last pap smear?__________________________________ Was it normal?_____________________
Please check if you have ever had: Family History:
1) ___ High blood pressure Please make a check if your mother, father,
2) ___ Blood clots or stroke/When?_______ sister or brother has had:
3) ___ Headaches/How often? ________ 28) ___ Diabetes
4) ___ Migraines/Diagnosed when?_______ 29) ___ High cholesterol
5) ___ Numbness in arms or legs 30) ___ Heart attack/Age_____
6) ___ High cholesterol 31) ___ High blood pressure
7) ___ Anemia Please make a check if your mother or sister
8) ___ Eye problems (not related to glasses) has had:
9) ___ Stomach or intestinal problems 32)___ Breast or ovarian cancer
10) ___ Liver or gallbladder problems 33)___ Osteoporosis
11) ___ Kidney or bladder problems 34) ___Your mother took DES (a hormone
12) ___ Varicose veins given to prevent miscarriages) during her
13) ___ Heart problems or murmur pregnancy with you
14) ___ Cancer 35)___You don’t know your family history
15) ___ Depression
16) ___ Diabetes/Age?______ Please check if you are currently having:
17) ___ Gynecological problems/surgery 36) ___ Bleeding after intercourse
18) ___ Breast disease/surgery 37) ___ Unusual vaginal bleeding
19) ___ Any surgeries not listed above 38) ___Vaginal itching
Procedure____________________ 39) ___ Unusual vaginal discharge
20) ___ Any serious illness not listed above 40) ___ Bumps in genital area
Illness _______________________ 41) ___ Pain/problem with urination
42) ___ Dizziness
Please check if : 43) ___ Blurred/double vision
21) ___ You are a smoker/Cigarettes per day ____ 44) ___Chest pain/shortness of breath
22) ___ You use alcohol/How much/day? _____________ 45) ___ Stomach/abdominal pain
23) ___ You feel alcohol/drugs are creating difficulties 46) ___ Pain/swelling in legs
in your life. 47) ___ Numbness/tingling in extremities
24) ___ You have concerns about sexuality or sexual intercourse 48) ___ Breast lump/discharge from nipples
25) ___ You do not feel safe in your current relationship 49) ___ Fever/chills
26) ___ You have experienced sexual assault/abuse 50) ___ Jaundice (yellowing of eyes/skin)
27) ___ You have experienced domestic violence 51) ___ Shoulder pain

Please answer the following questions regarding your periods:

52) How many days do your periods last? __________
53) Do you have periods every 24-35 days? __________
54) Do you have bleeding between periods? __________
55) How old were you when your periods began? __________
56) Do you have cramps requiring medication? __________
57) How many tampons/pads do you use on your heaviest days? __________
Please answer the following questions. They will help us determine your risk of having a sexually transmitted
infection.
58) At what age did you first have sexual intercourse? ______
59) Are you currently having sexual intercourse? _____
60) Does your current partner have other partners? _____
61) How many partners have you had sexual intercourse with in the past year? _____
62) Are your sexual partners _____ men _____women _____ both
63) Do you use condoms? _____ always _____ occasionally _____never
64) Have you ever had _____ Chlamydia _____Gonorrhea _____ Trichomonas _____ Syphilis _____ Genital Herpes
_____ Genital warts _____Pelvic Inflammatory Disease (PID) _____ Other sexually transmitted infections
65) Gonorrhea and Chlamydia testing are available for a small additional cost. Do you desire this testing?
_____ Yes _____ No Client Signature:__________________________________
Birth Control History:
66) Check if you have ever used: ___Condoms ___Pills ___Spermicides ___Sponges ___Rhythm ___ Diaphragm
___ Cap ___ IUD ___ Norplant ___ Depo injections ___ Other _____________________________________
67) Describe any problems with past methods _______________________________________________________
68) What method(s) are you currently using? ______________________ How long _______ Problem? Yes No
69) What method(s) would you like today? ________________________________________________________
Pregnancy History:
70) Have you ever been pregnant? _____ If no. sign and date form below.
71) Have you ever had an infection after the birth of a child, abortion or miscarriage? ________________________
72) Number of living children ______
List your pregnancies in order below:
Number of weeks pregnant _______
Date pregnancy ended_________
How pregnancy ended ____abortion ____ miscarriage ____ live birth ____tubal pregnancy ____ fetal death/still born
What type of delivery _____ vaginal _____ c-section
Pregnancy complications ____ toxemia ____ genetic abnormality ____ gestational diabetes
Number of weeks pregnant _______
Date pregnancy ended _________
How pregnancy ended ____live birth ____ miscarriage ____ abortion ____tubal pregnancy ____ fetal death/still born
What type of delivery _____ vaginal _____ c-section
Pregnancy complications ____ toxemia ____ genetic abnormality ____ gestational diabetes
Client Signature ____________________________Staff Signature ________________________ Date _____________

Source: http://ung.edu/student-health-services/_uploads/files/WMHC-Medical-History.pdf