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Gynecologic Oncology Navicent Health
NEW Patient History
Name: ______________________________________
Date of Birth: _____________
What is the main reason for your visit to our office today? ________________________________________ Allergies and Reactions:
Doctor’s Name (list all)
What Kind of Doctor?
Have you had any of the following diseases or conditions? Condition
No
Heart Problems High Blood Pressure High Blood Cholesterol Anemia or other blood problems Lung Disease (asthma, emphysema, TB, …) Kidney Disease (failure, stones, infections, etc…) Bladder Problems Liver Disease (yellow jaundice, cirrhosis, hepatitis, etc…) Cancer & what kind? Arthritis & Where? Bleeding Problems (do you take blood thinners?) Blood Clots Diabetes or “Sugar” Thyroid Disease or Goiter Stomach Problems Gall Bladder Disease (gall stones or other) Seizures or Epilepsy Parkinson’s Disease Multiple Sclerosis Stroke or Paralysis Psychiatric or emotional problems Skin Problems (unusual or recently changed mole) Physical Restrictions & describe Page 1 of 4
Yes
Year Diagnosed
GYN History Menstrual
Menopausal? If yes, what year?_______ Post menopausal spotting / bleeding? YES NO
If no:
Length of periods _____________
Circle your flow of menstrual bleeding
Heavy
Moderate
Light
Circle your pain level with your period
Severe
Moderate
Mild None
PAP Smears
Date of last pap smear ________________
Results __________________________________
Have you ever had an abnormal pap smear?
YES
If yes, what treatment did you receive? __________________________________________________
NO
Sexual Intercourse (check the ones below that you experience with intercourse) Pain _____
Dryness _____ Decreased Desire _____
Bleeding or Spotting _____
Mammogram
Have you had a mammogram (circle)
YES
NO
If yes, when was it done? ________________________
Results? _____________________
Obstetrical History Pregnancy
Number of pregnancies ______________
Number of c‐sections _______________________
Number of live births ________________
Number of miscarriages _____________________
Number of abortions ________________
Social History Marital Status (circle)
Single
Married
Widowed
Page 2 of 4
Divorced
Separated
Living Arrangements (circle) Live Alone Family Assisted Living Facility Tobacco Use
Cigarettes (how many) ______
Snuff/Chewing Tobacco (how much) ____________________
Cigars (how many) ________
Do you use alcohol? YES (how much) ____________________________
NO
Family Cancer History Relative
Type of Cancer
Previous Hospitalizations/Surgeries/Procedures YEAR
Reason or Procedure/Surgery
Page 3 of 4
Age
Current Medications (include herbals and over‐the counter products) Med/Herbal Name
How many times per day?
Dose
Reviewed By: __________________________________
Page 4 of 4
How long have you been taking?
Date: ___________________