Client Medical History

Client Medical History

Please complete this form to the best of your ability. Your nurse will review it with you and answer any questions you may have.
Legal Name

First NameLast Name
DOB:

MonthDayYear

Menstrual
- Age of first period
- First day of last period
- How often do you have periods?
- How many days does your period last?
- Using the pain scale of 1 - 10, where 1 is the least painful and 10 is the most painful, enter in the level of pain you experience during your periods.
- What level of pain are your periods?
- How many tampons/pads do you use a day?
- What is the flow of your pads / tampons?
- Have you gone through menopause?
- What age?
- Date of last PAP smear?
  
  MonthDayYear
- Was it normal?
- Have you ever had an abnormal PAP smear?
- When?
- Have you ever had surgery on your reproductive organs?
- What kind of surgery?
  Ex. Cryo, LEEP, Hysterectomy, etc.)

Pregnancy
- Number of pregnancies
- Number of full term births
- Number of premature births
- Additional information about pregnancies and/or complications:
- Were you HIV + during any pregnancy?
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Name of hospital?
- Your your baby HIV+ after birth?
- Did you have any complications during these pregnancies while HIV+?
- Were you on HIV medications at the time of your pregnancy?

Breast Health
Have you ever had any breast problems?
What kind?
Have you ever had any surgeries or procedures on your breasts?
What kind?
Where?
When?
Date of last mammogram?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Was it normal?
Have you ever had an abnormal mammogram?
When?

Your signature here means you have filled out our Medical History form to the best of your ability.
Signature
Today's Date

MonthDayYear
Should be Empty: