Fill out Your Personal Medical History Form because this is the basis for any good healthcare relationship. It is a valuable resource you should update at least annually and review with your healthcare provider. This is one of the questionnaires included in "Speaking of Menopause"
To fill out the form save it as text in a file on your computer. Then you can either print it out and fill it out by hand or you can open it in a word processing program and fill it out.
Personal Health History Questionnaire
MY PERSONAL MEDICAL HISTORY
Name: ____________________ Height:____________________
Date of Birth:_______________ Weight:____________________
What concerns do Karen's patients share?
Karen, I'm too embarrassed to talk about my problem.
Race
[ ] Caucasian [ ] Asian [ ] African-American [ ] American Indian
[ ] Hispanic [ ] Other:
Infectious Diseases
Check any of the following diseases that you have had:
[ ] Measles (hard, seven-day, Rubeola)M
[ ] German measles (three-day, Rubella)
[ ] Mumps
[ ] Hepatitis A (usually from contaminated food)
[ ] Hepatitis B (usually transmitted by contaminated blood or sexually)
[ ] Hepatitis C (usually transmitted by contaminated blood or sexually)
[ ] HIV (the virus that causes AIDS)
[ ] Tuberculosis
[ ] Rheumatic fever
[ ] Polio
[ ] Gonorrhea
[ ] Chlamydia
[ ] Herpes
[ ] Syphilis
[ ] Condyloma (genital warts)
Surgery
Please list all the surgeries that you have had:
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
What concerns do Karen's patients share?
Karen, bleeding problems really worry me!
Menstrual History
What age were you when your periods started?______________________
How many days does your period usually last?______________________
How many days are between your periods?_________________________
How many pads or tampons do you use on a heavy day? ______________
How much pain do you have with your periods?_____________________
[ ] Mild
[ ] Moderate
[ ] Severe
Has there been a change in the amount of pain you have?
[ ] Yes
[ ] No
Gynecologic History
When was your last pap test?____________________
Have you ever had an abnormal pap test?
[ ] Yes [ ] No
If yes, did you have any of the following treatments? (See Glossary for definitions).[ ] Cryo (freezing of your cervix)
[ ] Leep (removal of part of your cervix by electric cautery)
[ ] Conization (removal of part of cervix surgically in hospital)
[ ] Hysterectomy (removal of uterus only)
Check any of the following vaginal problems you have:
[ ] Discharge
[ ] Itching
[ ] Burning
[ ] Odor
[ ] Pain with intercourse
[ ] Dryness or inability to lubricate
[ ] Sores
[ ] Growths
Has your mother or a sister had cancer of any of the following:
[ ] Uterus
[ ] Ovaries
[ ] Vagina
[ ] Fallopian tubes
Contraceptive History
Check any of the following birth control methods you have used:
[ ] Birth control pills
[ ] Patch
[ ] Vaginal ring
[ ] IUD (intrauterine device)
[ ] Diaphragm
[ ] Cervical cap
[ ] Sponge
[ ] Spermicide
[ ] Norplant
[ ] Depo Provera
[ ] Natural family planning
[ ] Tubal Ligation
Pregnancy History
How many times have you been pregnant? ____________________
How many live births have you had? ____________________
How many miscarriages have you had? ____________________
How many abortions have you had? ____________________
Have you had any of the following complications with pregnancy?
[ ] High blood pressure
[ ] Diabetes
What concerns do Karen's patients share?
Karen, is it normal for sexual desire to decrease after menopause?
Sexual History
What age were you when you had intercourse the first time?_______
Are you currently sexually active?
[ ] Yes
[ ] No
If yes, check any of the following that apply to you:
[ ] I am satisfied with my sex life.
[ ] I have orgasms.
[ ] I have pain with intercourse.
[ ] I have decreased sexual desire.
Have you ever been touched in a sexual way that made you uncomfortable? If yes, have you ever spoken to anyone about it?
[ ] Yes
[ ] No
If you had a professional person with whom you felt comfortable, would you be willing to discuss this?
[ ] Yes
[ ] No
What concerns do Karen's patients share?
Karen, My mother had breast cancer and I'm afraid!Breast History
Do you do self breast exams?
[ ] Yes
[ ] No
If yes, how often do you do them? _____________________
If no, why not? ____________________________________
Have you had a mammogram?
[ ] Yes
[ ] No
If yes, when? ____________________________________
If no, why not? ____________________________________
Has your mother or a sister had breast cancer?
[ ] Yes
[ ] No
Do you have any lumps in your breasts that you feel are new?
[ ] Yes
[ ] No
Have you had any discharge from your nipples?
[ ] Yes
[ ] No
If yes, what was the color of the discharge?
[ ] White
[ ] Clear
[ ] Red
[ ] Brown
[ ] Black
[ ] Green
Do you have any breast pain?
[ ] Yes
[ ] No
Nutrition History
Do you drink alcohol?
[ ] Yes
[ ] No
If yes, how much per day?_____________ ounces
(There is one ounce of alcohol in one 12 oz. beer, 6 oz. wine, or 2 oz. 100-proof liquor.)
Do you drink carbonated beverages?
[ ] Yes
[ ] No
If yes, how much per day? ________ cans/bottles
Do you drink coffee?
[ ] Yes
[ ] No
If yes, how much per day? ________ cups
How many servings of dairy products do you eat each day?______servings
How many servings of meat products do you eat each day? ______servings
How many servings of fruits and vegetables do you eat each day?______servings
How many servings of grain products do you eat each day? ______servings
Do you eat chocolate?
[ ] Yes
[ ] No
Cardiovascular History
Have you ever had high blood pressure?
[ ] Yes
[ ] No
Have you taken medication for high blood pressure?
[ ] Yes
[ ] No
Have you ever had blood clots in your veins or arteries?
[ ] Yes
[ ] No
Have you ever had a heart attack?
[ ] Yes
[ ] No
Has anyone related to you ever had a heart attack?
[ ] Yes
[ ] No
If yes, what relation were they to you? ________________________
At what age did it happen to them? ________________________
Have you ever smoked cigarettes?
[ ] Yes
[ ] No
Do you smoke cigarettes now?
[ ] Yes
[ ] No
If yes, how many per day? ________________________
Would you consider quitting?
Do you get regular physical exercise?
[ ] Yes
[ ] No
If yes, please describe: ________________________
If no, what keeps you from exercising? ________________________
Bladder History
Do you have trouble emptying your bladder?
[ ] Yes
[ ] No
Do you lose urine when you cough, sneeze, or run?
[ ] Yes
[ ] No
Do you lose urine on the way to the toilet?
[ ] Yes
[ ] No
Have you had bladder infections?
[ ] Yes
[ ] No
Do you empty your bladder more than 10 times a day?
[ ] Yes
[ ] No
Bowel History
Do you have constipation?
[ ] Yes
[ ] No
Do you have frequent diarrhea?
[ ] Yes
[ ] No
Do you have trouble with hemorrhoids?
[ ] Yes
[ ] No
Do you have relatives with bowel or colon cancer?
[ ] Yes
[ ] No
Have you noticed blood with your bowel movements?
[ ] Yes
[ ] No
Have you had tests for blood in your bowel movements?
[ ] Yes
[ ] No
If you are over 50, have you had a sigmoidoscopy or colonoscopy?
[ ] Yes
[ ] No
What concerns do Karen's patients share?
Karen, I've always been so calm. What's happening?Emotional History
Check any of the following that you have experienced:
[ ] Crying often
[ ] Feeling depressed for more than two weeks
[ ] Feeling like you want to die
[ ] Feeling helpless
[ ] Feeling hopeless
[ ] Feeling "trapped"
[ ] Wanting to be alone most of the time
[ ] Feeling guilty
[ ] Feeling like a failure
[ ] Waking up early (before you want to)
[ ] Difficulty falling asleep
[ ] Feeling nervous most of the time
[ ] Worrying most of the time
Has anyone closely related to you suffered with emotional health problems?
[ ] Yes
[ ] No
Write a sentence about how you feel most of the time:
Social History
Describe your occupation: _______________________________
How many years of schooling have you had? __________years
Would you like to have more education?
[ ] Yes
[ ] No
If yes, what keeps you from going back to school?
Are you:
[ ] Single
[ ] Married
[ ] Widowed
[ ] Divorced
Are you happy with your marital status?
[ ] Yes
[ ] No
Domestic violence occurs in many relationships and may cause terrible injury, both physical and emotional.
Have you ever been physically or emotionally abused by someone with whom you had a close relationship?
[ ] Yes
[ ] No
If yes, have you discussed this with a professional?
[ ] Yes
[ ] No
If you do not have someone with whom you feel you can discuss an abuse problem, please refer to the agencies listed in the Resource section in the back of your Personal Healthcare Plan.
Is there anything else you would like your healthcare provider to know about you and your health?
Copyright ©1995-2004 Karen Lee, A.R.N.P.,
Advanced Registered Nurse Practitioner
Certified Menopause Practitioner
