disease, such as those with a family history of eye disease, diabetes or high “Much like mammograms and diabetes screenings, regular eye exams will help …

NEICAC FAMILY PLANNING

MEDICAL HISTORY

Review of Systems

Name:________________________________________________________
Birthdate:_________________ Age:________
Last First
Initial

Reason for your visit
today:______________________________________________________________________
_____
Family Planning serves a wide range of women We have tried to make this
form as complete as possible, realizing that some questions will not apply
to every womans particular circumstances All information is strictly
confidential

CONTRACEPTIVE HISTORY

Check all birth control methods you have used: Pill DepoProvera
Lunelle IUD Condom Sterilization Diaphragm
Foam/Suppository Natural Family Planning Rhythm Withdrawal
Other_________________________________________

|YES |NO | |
| | |Do you or your partner use birth control now? |
| | |If yes, what methods do you use?_________________________ How long have |
| | |you used this
method?_____________________ |
| | |Have you had problems with this or any birth control method? If yes, |
| | |explain:____________________________________________ |
| | |Do you plan to get pregnant in the next year? |
| | |Do you want a birth control method today? If yes, what |
| | |method?_____________________________________________________ |

SEXUAL HISTORY

Your answers to the following questions will help us assess your risk for
cervical cancer and sexually transmitted infections STIs
Age at first intercourse:________________
|YES |NO | |
| | |Are you sexually active now? Check all that apply: Vaginal Anal Oral |
| | |Other When did you last have sex?__________ |
| | |Do you take precautions against sexually transmitted infections? |
| |
|Explain:________________________________________________ |
| | |Have you had more than one or a new sexual partner in the past year? Are |
| | |your partners: Male Female Both |
| | |Do you feel that any of your partners have put you at risk for sexually |
| | |transmitted infections or HIV? |
| | |Do you want to be tested for sexually transmitted infections? |
| | |Do you have any other questions or concerns about sex that you would like to|
| | |discuss during this visit? |
| | |Explain:____________________________________________________________________|
| | |________________________________ |
| | |No of partners this year: ________ No of lifetime partners: |
| | |__________ |

SOCIAL/HEALTH RISK HISTORY

10/2004
Please list any ALLERGIES, including drug, metal, skin allergies or
irritants, or rubber/latex sensitivity___________________________________
____________________________________________________________________________
___________________________________________
FAMILY HISTORY
If you are adopted, check and skip to the next section
Has anyone in your immediate family ever had the following? If yes,
indicate father F, mother M, brother B, or sister S
______ No longer living Age/Cause of death:_______________________
_______Breast, Ovarian or Uterine Cancer age at onset:_________
______ Heart Attack/Heart Disease/Surgery Age at onset:_____________
_______Other Cancer
______ High Blood Cholesterol/High Blood Pressure
_______Diabetes Yes No
Women born 1940-1970: Did your mother take DES hormones during her
pregnancy with you? Yes No
MEDICAL HISTORY List current medications including herbs and
over the counter
meds:_________________________________

____________________________________________________________________________
________________
|YES |NO | |
| | |Have you ever had surgery or been a patient in a hospital? |
| | |If yes, |
| | |describe:___________________________________________________________________|
| | |___________________________ |
| | |Are you now, or have you been, under a doctors care for a serious illness |
| | |or condition? |
| | |If yes, |
| | |describe:___________________________________________________________________|
| | |___________________________ |
| | | |
| | |Do you have another source of health care? |
| |
|Where?________________________________________________________________ |

FILL THIS OUT IF YOU ARE UNDER 18 YEARS OLD
YES NO
Are your parents aware of your visit to Family Planning?
If not, did you discuss your plans to come to the clinic with
another adult? Who?__________________________________
Would you like information on talking to your parents about
sexuality?
Are you in a relationship where you are being forced to have
sexual relations?

TO THE BEST OF MY KNOWLEDGE, THIS INFORMATION IS COMPLETE AND CORRECT

Patient Signature___________________________________________ Date of
Birth__________________ Date_______________

Comments: Staff
Signature_____________________

———————–
Clinician:____________________
Clinic Location:_______________
Date:________________________
Chart
______________________

Source:neicac.org

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disease, such as those with a family history of eye disease, diabetes or high “Much like mammograms and diabetes screenings, regular eye exams will help …

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