Medical History

Patient Full Name:

Date:

Patient Date of Birth:

Current Smoker?:

Yes No

If yes, please indicate start date:

How many per day?

If NO, do you have a history of smoking?

Yes No

If yes, please indicate quit date

History or current use of illegal or recreational substances?

Yes No

If YES, indicate start/last used date, type of drug, and how much per day

Current or any use of Alcohol?

Yes No

If so/yes, how many drinks daily:

Weekly

Date of Last Menstrual Cycle:

Age at First Menstrual Cycle:

How often do you have your cycles?

How many days do your cycles last?

History of Abnormal Pap Smears?

History of Sexually Transmitted Disease(s)?

Current Birth Control Method:

OB PATIENTS: Please list years of all pregnancies and outcomes

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