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Patient Medical History and Review of Systems — Female
Complete one patient’s medical history and review of systems (no physical exam included).
Please complete this form before your appointment. Review of systems means questions about symptoms you may have. Have your medication list and allergy information available. Enter information for one patient only. Answer what you know; you may leave optional questions blank or choose Not sure or Prefer to discuss. Please review your answers and select Submit history and ROS when finished. Your care team will review them for your visit.
This form is not monitored for emergencies. Call 911 for an emergency.
Encounter / Patient Details
Encounter
Upcoming appointment date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Best contact phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
example@example.com
Specialty for this visit
*
Please Select
Urology
Gynecology
Interventional radiology/vascular care
Other or not sure
Main reason for visit
*
Please Select
Urology: urinary symptoms
Urology: enlarged prostate
Urology: kidney stones
Urology: blood in urine
Urology: urinary infections
Urology: erectile/sexual health
Urology: testosterone concerns
Urology: vasectomy
Urology: second opinion
Urology: other
Gynecology: annual visit
Gynecology: abnormal bleeding
Gynecology: fibroids
Gynecology: pelvic pain
Gynecology: vaginal symptoms
Gynecology: menopause symptoms
Gynecology: contraception
Gynecology: abnormal Pap/HPV follow-up
Gynecology: bladder concerns
Gynecology: other
Interventional radiology/vascular care: prostate artery embolization
Interventional radiology/vascular care: fibroid embolization
Interventional radiology/vascular care: leg veins
Interventional radiology/vascular care: leg circulation/PAD
Interventional radiology/vascular care: other
Other or not sure
Choose the option that best matches your visit.
Main concern and when it started
Current medications
Names and doses if known. You can write none or not sure.
Patient full name
*
First Name
Middle Name
Last Name
Allergy or reaction details
Fill this in only if you selected Yes.
Relevant medical conditions or major surgeries
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical record number
Date completed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Practice/site
Office/location
Visit type
Please Select
New patient
Follow-up
Annual exam
Consultation
Procedure visit
Telehealth
Other
Primary clinician
First Name
Middle Name
Last Name
Referring clinician
First Name
Middle Name
Last Name
Primary care clinician
First Name
Middle Name
Last Name
Preferred name
Pronouns
Please Select
She/her
He/him
They/them
Other
Gender identity
Please Select
Woman
Man
Nonbinary
Transgender woman
Transgender man
Genderqueer
Another identity
Prefer not to say
Relevant anatomy or hormone-therapy context
Preferred language
Please Select
English
Spanish
Mandarin
Cantonese
French
Arabic
Hindi
Portuguese
Russian
Other
Interpreter used
Yes
No
Interpreter name/ID
Who is completing this form? (patient or person helping)
Please Select
Patient
Parent/guardian
Partner
Family member
Caregiver
Other
History source
Please Select
Patient
Person assisting
Both
Not sure
Person assisting - relationship
Anything you are unsure about or would like to discuss at your visit
Chief Concern and HPI
Chief Concern
Onset Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Duration
Location
Character / Description
Severity
Please Select
Mild
Moderate
Severe
Very severe
Unable to determine
Frequency / Timing
Please Select
Constant
Intermittent
Occasional
Daily
Weekly
Nightly
With activity
At rest
Other
Course Since Onset
Please Select
Improving
Worsening
Unchanged
Fluctuating
Resolved
Unsure
Radiation
Aggravating Factors
Movement
Eating
Stress
Standing
Sitting
Lying down
Exertion
Intercourse
Urination
Bowel movement
Other
Relieving Factors
Rest
Medication
Heat
Ice
Changing position
Food
Fluid intake
Bowel movement
Urination
Other
Associated Symptoms
Functional Impact
Prior Episodes
Please Select
No
Yes, similar episode
Yes, multiple episodes
Unsure
Previous Evaluation
Previous Treatments
Treatment Response
Please Select
Not tried
No relief
Partial relief
Good relief
Complete relief
Worsened
Unsure
Patient Goals / Questions
HPI Summary
Past Medical History
High blood pressure
Yes
No
Not sure
Prefer to discuss
Coronary artery disease / heart attack
Yes
No
Not sure
Prefer to discuss
Heart failure
Yes
No
Not sure
Prefer to discuss
Heart rhythm disorder
Yes
No
Not sure
Prefer to discuss
Stroke / TIA
Yes
No
Not sure
Prefer to discuss
Blood clot / DVT / PE
Yes
No
Not sure
Prefer to discuss
Bleeding disorder
Yes
No
Not sure
Prefer to discuss
Diabetes
Yes
No
Not sure
Prefer to discuss
Thyroid disease
Yes
No
Not sure
Prefer to discuss
Asthma
Yes
No
Not sure
Prefer to discuss
Chronic obstructive pulmonary disease
Yes
No
Not sure
Prefer to discuss
Sleep apnea
Yes
No
Not sure
Prefer to discuss
Kidney disease
Yes
No
Not sure
Prefer to discuss
Kidney stones
Yes
No
Not sure
Prefer to discuss
Recurrent urinary tract infection
Yes
No
Not sure
Prefer to discuss
Liver disease
Yes
No
Not sure
Prefer to discuss
Gastrointestinal disease
Yes
No
Not sure
Prefer to discuss
Neurologic disorder
Yes
No
Not sure
Prefer to discuss
Seizures
Yes
No
Not sure
Prefer to discuss
Arthritis / musculoskeletal disease
Yes
No
Not sure
Prefer to discuss
Cancer
Yes
No
Not sure
Prefer to discuss
Depression
Yes
No
Not sure
Prefer to discuss
Anxiety
Yes
No
Not sure
Prefer to discuss
Other mental-health condition
Yes
No
Not sure
Prefer to discuss
Infectious disease affecting care
Yes
No
Not sure
Prefer to discuss
Other medical conditions
Yes
No
Not sure
Prefer to discuss
Medical history details and approximate dates
Cancer type / site and treatment
Hospitalizations
Significant infections
Implanted devices
Anesthesia problems
Blood transfusion history
Medications
Medication list status
Complete
Incomplete
Unknown
Medication 1 - Medication name
Medication 1 - Strength/dose
Medication 1 - Route
Please Select
Oral
Topical
Inhaled
Injection
Sublingual
Rectal
Vaginal
Ophthalmic
Otic
Nasal
Other
Medication 1 - Frequency
Medication 1 - Indication
Medication 1 - Prescriber
Medication 1 - Brand name
Medication 2 - Medication name
Medication 2 - Strength/dose
Medication 2 - Route
Please Select
Oral
Topical
Inhaled
Injection
Sublingual
Rectal
Vaginal
Ophthalmic
Otic
Nasal
Other
Medication 2 - Frequency
Medication 2 - Indication
Medication 2 - Prescriber
Medication 2 - Brand name
Medication 3 - Medication name
Medication 3 - Strength/dose
Medication 3 - Route
Please Select
Oral
Topical
Inhaled
Injection
Sublingual
Rectal
Vaginal
Ophthalmic
Otic
Nasal
Other
Medication 3 - Frequency
Medication 3 - Indication
Medication 3 - Prescriber
Medication 3 - Brand name
Medication 4 - Medication name
Medication 4 - Strength/dose
Medication 4 - Route
Please Select
Oral
Topical
Inhaled
Injection
Sublingual
Rectal
Vaginal
Ophthalmic
Otic
Nasal
Other
Medication 4 - Frequency
Medication 4 - Indication
Medication 4 - Prescriber
Medication 5 - Medication name
Medication 5 - Strength/dose
Medication 5 - Route
Please Select
Oral
Topical
Inhaled
Injection
Sublingual
Rectal
Vaginal
Ophthalmic
Otic
Nasal
Other
Medication 5 - Frequency
Medication 5 - Indication
Medication 5 - Prescriber
Additional medications
Anticoagulant/antiplatelet medication details
Allergies
Allergy status
No known allergies
Environmental allergies
Food allergies
Medication allergies
Other known allergies
Allergen 1 - Substance
Allergen 1 - Reaction
Allergen 1 - Severity
Please Select
Mild
Moderate
Severe
Unknown
Allergen 1 - Approximate reaction date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Allergen 2 - Substance
Allergen 2 - Reaction
Allergen 2 - Severity
Please Select
Mild
Moderate
Severe
Unknown
Allergen 2 - Approximate reaction date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Allergen 3 - Substance
Allergen 3 - Reaction
Allergen 3 - Severity
Please Select
Mild
Moderate
Severe
Unknown
Allergen 3 - Approximate reaction date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Latex allergy
No
Yes
Unknown
Contrast-agent reaction
Procedures and Surgeries
Procedure 1
Approximate date of Procedure 1
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Facility / clinician for Procedure 1
Complications from Procedure 1
Procedure 2
Approximate date of Procedure 2
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Approximate date of Procedure 3
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Facility / clinician for Procedure 2
Complications from Procedure 2
Procedure 3
Facility / clinician for Procedure 3
Procedure 4
Approximate date of Procedure 4
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Facility / clinician for Procedure 4
Complications from Procedure 4
Complications from Procedure 3
Additional procedures
Prior anesthesia complications
Family History
Is family history available?
Yes
No
Unknown
Family member 1
First Name
Last Name
Family member 1 — Relative / relationship
Family member 1 — Condition
Family member 1 — Age at diagnosis
Family member 1 — Additional detail
Family member 2
First Name
Last Name
Family member 2 — Relative / relationship
Family member 2 — Condition
Family member 2 — Age at diagnosis
Family member 2 — Additional detail
Family member 3
First Name
Last Name
Family member 3 — Relative / relationship
Family member 3 — Condition
Family member 3 — Age at diagnosis
Diabetes in family
Yes
No
Not sure
Known hereditary cancer syndrome in family
Yes
No
Not sure
Heart disease in family
Yes
No
Not sure
Stroke in family
Yes
No
Not sure
High blood pressure in family
Yes
No
Not sure
High cholesterol in family
Yes
No
Not sure
Thyroid disease in family
Yes
No
Not sure
Autoimmune disease in family
Yes
No
Not sure
Depression or anxiety in family
Yes
No
Not sure
Asthma or COPD in family
Yes
No
Not sure
Additional family history details
Family member 3 — Additional detail
Prostate cancer in family?
Yes
No
Unknown
Breast cancer in family?
Yes
No
Unknown
Ovarian cancer in family?
Yes
No
Unknown
Colorectal cancer in family?
Yes
No
Unknown
Kidney or bladder cancer in family?
Yes
No
Unknown
Early cardiovascular disease in family?
Yes
No
Unknown
Social and Functional History
Tobacco status
Never
Former
Current
Prefer not to say
Tobacco type
Please Select
Cigarettes
Cigars
Pipe
Chewing tobacco
Snuff
Other
Tobacco amount
Years used
Quit date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Vaping status
Never
Former
Current
Prefer not to say
Alcohol frequency
Please Select
Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
Prefer not to say
Alcohol amount
Recreational substance use
No
Yes
Prefer not to say
Substance details
Occupation
Occupational exposures
None
Dust
Fumes
Chemicals
Noise
Radiation
Bloodborne exposure
Other
Living situation
Please Select
Lives alone
With spouse/partner
With family
With roommates
Assisted living
Skilled nursing facility
Other
Support system
Please Select
Strong
Moderate
Limited
None
Prefer not to say
Activity/exercise
Please Select
Sedentary
Lightly active
Moderately active
Very active
Unable to exercise
Prefer not to say
Dietary considerations
Sleep
Please Select
No concerns
Difficulty falling asleep
Frequent waking
Too little sleep
Too much sleep
Sleep apnea
Other
Mobility limitations
No
Yes
Prefer not to say
Help with daily activities
No assistance needed
Some assistance needed
Full assistance needed
Prefer not to say
Falls history
No falls
1 fall
2 or more falls
Prefer not to say
Home safety concerns
None
Stairs
Poor lighting
Loose rugs/clutter
Lack of grab bars
Unsafe bathroom
Fire safety concerns
Other
Social barriers to care
None
Transportation
Cost
Childcare
Work schedule
Language barrier
Housing instability
Food insecurity
Other
Advance-directive status
Please Select
Not completed
Completed
Unsure
Prefer not to say
Healthcare decision-maker
First Name
Middle Name
Last Name
Sexual and Reproductive History
Sexual activity
Yes
No
Prefer not to say
Partner or anatomy considerations relevant to care
Sexual health concerns
History of sexually transmitted infections
Concerns about sexually transmitted infection testing
Contraception or barrier use
Fertility goals
Trying to conceive
Avoiding pregnancy
Not sure
Not applicable
Prefer not to say
Hormone medications details
Urinary History
Pain or burning with urination
No
Yes
Unsure
Urinary frequency
No
Yes
Unsure
Urinary urgency
No
Yes
Unsure
Nighttime urination
No
Yes
Unsure
Weak urinary stream
No
Yes
Unsure
Hesitancy
No
Yes
Unsure
Straining to urinate
No
Yes
Unsure
Interrupted or intermittent stream
No
Yes
Unsure
Incomplete bladder emptying
No
Yes
Unsure
Urinary retention
No
Yes
Unsure
Urinary leakage
No
Yes
Unsure
Visible blood in urine
No
Yes
Unsure
Pelvic or bladder pain
No
Yes
Unsure
Flank pain
No
Yes
Unsure
Recurrent urinary infections
No
Yes
Unsure
Onset and duration of urinary symptoms
Number of nighttime voids
Leakage triggers
Coughing
Sneezing
Laughing
Exercise
Urgency
Standing up
Lifting
Other
Prior urinary procedures
Prior catheter use
No
Yes
Unsure
Urologic history details
Review of Systems
Fever
Yes
No
Not sure
Prefer to discuss
Chills
Yes
No
Not sure
Prefer to discuss
Fatigue
Yes
No
Not sure
Prefer to discuss
Unintentional weight change
Yes
No
Not sure
Prefer to discuss
Night sweats
Yes
No
Not sure
Prefer to discuss
Rash
Yes
No
Not sure
Prefer to discuss
Nonhealing skin lesion
Yes
No
Not sure
Prefer to discuss
Vision change
Yes
No
Not sure
Prefer to discuss
Eye pain
Yes
No
Not sure
Prefer to discuss
Hearing change
Yes
No
Not sure
Prefer to discuss
Nasal congestion
Yes
No
Not sure
Prefer to discuss
Sore throat
Yes
No
Not sure
Prefer to discuss
Chest pain
Yes
No
Not sure
Prefer to discuss
Palpitations
Yes
No
Not sure
Prefer to discuss
Leg swelling
Yes
No
Not sure
Prefer to discuss
Shortness of breath
Yes
No
Not sure
Prefer to discuss
Cough
Yes
No
Not sure
Prefer to discuss
Wheeze
Yes
No
Not sure
Prefer to discuss
Nausea
Yes
No
Not sure
Prefer to discuss
Vomiting
Yes
No
Not sure
Prefer to discuss
Abdominal pain
Yes
No
Not sure
Prefer to discuss
Diarrhea
Yes
No
Not sure
Prefer to discuss
Constipation
Yes
No
Not sure
Prefer to discuss
Blood in stool
Yes
No
Not sure
Prefer to discuss
Joint pain
Yes
No
Not sure
Prefer to discuss
Muscle pain
Yes
No
Not sure
Prefer to discuss
Back pain
Yes
No
Not sure
Prefer to discuss
Headache
Yes
No
Not sure
Prefer to discuss
Dizziness
Yes
No
Not sure
Prefer to discuss
Weakness
Yes
No
Not sure
Prefer to discuss
Numbness
Yes
No
Not sure
Prefer to discuss
Syncope
Yes
No
Not sure
Prefer to discuss
Heat/cold intolerance
Yes
No
Not sure
Prefer to discuss
Excessive thirst
Yes
No
Not sure
Prefer to discuss
Easy bruising
Yes
No
Not sure
Prefer to discuss
Abnormal bleeding
Yes
No
Not sure
Prefer to discuss
Depressed mood
Yes
No
Not sure
Prefer to discuss
Anxiety symptoms
Yes
No
Not sure
Prefer to discuss
Additional ROS details
Female Gynecologic and Obstetric History
Last menstrual period
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Menstrual status
Please Select
Regular cycles
Irregular cycles
Pregnant
Breastfeeding
Perimenopausal
Postmenopausal
Amenorrhea
Unknown
Cycle interval (days)
Bleeding duration (days)
Bleeding pattern
Please Select
Light
Moderate
Heavy
Spotting only
Variable
Absent
Unknown
Age at menarche
Age/date at menopause
Pregnancy possibility
Please Select
No
Yes
Unsure
Not applicable
Current pregnancy status
Please Select
Not pregnant
Pregnant
Possible pregnancy
Postpartum
Post-abortion
Unknown
Gravida
Term births
Preterm births
Pregnancy losses / spontaneous abortions
Induced abortions
Ectopic pregnancies
Living children
Pregnancy/delivery complications
Contraceptive method
Please Select
None
Barrier method
Combined hormonal method
Progestin-only method
IUD
Implant
Fertility awareness
Sterilization
Partner sterilization
Other
Last cervical screening date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Cervical screening results
Please Select
Normal
Abnormal
Unsure
Not done
Pending
Other
HPV history / vaccination
Please Select
Completed
Partial
Not vaccinated
Prior HPV infection
Unknown
Prior cervical abnormalities / procedures
Last breast imaging date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Last breast imaging result
Please Select
Normal
Abnormal
Dense breasts
Incomplete
Not done
Unknown
Other
Prior breast disease / surgery
Gynecologic surgeries
Hysterectomy details
Ovary / tube surgery
Hormone-therapy history
Relevant obstetric / gynecologic history details
Heavy menstrual bleeding
Please Select
No
Yes
Previously
Unknown
Bleeding between periods
Please Select
No
Yes
Previously
Unknown
Bleeding after menopause
Please Select
No
Yes
Previously
Not applicable
Unknown
Painful periods
Please Select
No
Yes
Previously
Unknown
Pelvic pain
Please Select
No
Yes
Previously
Unknown
Vaginal discharge / irritation
Please Select
No
Yes
Previously
Unknown
Vaginal dryness
Please Select
No
Yes
Previously
Unknown
Pain with intercourse
Please Select
No
Yes
Previously
Not applicable
Unknown
Vaginal bulge / prolapse symptoms
Please Select
No
Yes
Previously
Unknown
Breast lump
Please Select
No
Yes
Previously
Unknown
Nipple discharge
Please Select
No
Yes
Previously
Unknown
Medication allergies
*
No known allergies
Yes
Not sure
Pain
Pain
No pain
Taking medications
Yes
No
Condition, surgery, or Other
Condition
Surgery
Other
Submit
Should be Empty: