The College Of WILLIAMSMARY Student HealthCenter
FAMILYHISTORY - Has anyone in your immediate family had trouble with the following? Include mother (M), father (F), brother (B), sister (S), aunt (A), grandmother (GM
Clotting disorder Breast disease Breast cancer in female relative
GYN cancer High blood pressure Stroke Blood clots
age 50 in immediate family Osteoporosis
MEDICAL HISTORY - Information about you YesNow No
Headaches/frequent Migraine headaches Severe depression Severe mood changes Cancer Eating disorder Diabetes
Thyroid problem Breast disease High blood pressure Shortness of breath Heart disease/problem Blood clots Liver disease
Urinary tract infections in last year Smoking # of cigarettes /wk how long? Alcohol use # drinks/day # drinks/wk Recreational drug use Regular exercise
Pelvic infections (PID) Pelvic surgery Abnormal pap report Positive HPV test
Sexually transmitted infections (STIs) type Vaginal infections type
Pregnancy/abortion Gardasil vaccine
First day of last menstrual period
Have you had unprotected sex (no condoms) since your last menstrual period? No / Yes Any missed birth control pills? Plan B taken in last year?NoNoYes Yes. Are you currently using contraception? Any previously used contraceptive method?
Any other health care concerns you would like to discuss?
Describe FibrousD/C R: NlAbnlCystic mass L: NlAbnlFibrousCystic massD/CDescribe indicated
Vagina: NlAbnl D/C Condyloma Other: Describe Cervix:
Cervicitis NlErosionEversion Abnl
Mucopurulent D/C Cervical motion tenderness Other: Uterus:
NlEnlargedNodular Smooth Abnl MLRLOther: Ant/post Adnexal:
Abnl R: NlTender massDescribe Abnl L: NlTender massDescribe
NlBloodHemorrhoid AbnlMassOther: Fissure
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