Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696592679461.pdf (United States)
Label Confidential North Carolina Department of Health and Human Services Division of Public Health Women’s and Children’s Health Section FEMALE REPRODUCTIVE HEALTH HISTORY Date: ________________________ A.

GENERAL INFORMATION (Please complete the following) What is the reason for your visit?
_________________________________________________________________________________ Emergency contact: ___________________________________________________________________________________________ May we contact you by mail?

 Yes  No By phone?

 Yes  No Your phone number is: ______________________________ Do you have a primary care provider?

 Yes  No If yes, who?


______________________________________________________ Highest grade completed in school __________ Occupation __________________________________________________________________________________________________ Special Needs/Primary Language _____________________ B.
MEDICAL HISTORY, HOSPITALIZATIONS, MEDICATIONS List hospitalizations, surgeries and dates: ___________________________________________________________________________ Medications: Do you take a multivitamin with folic acid?

 Yes  No Take any medications (prescription or over the counter), diet or herbal supplements?

 Yes  No If yes, what?


________________________________________________________________ Self and Family Medical History: Put an X under SELF and/or X under FAMILY (parent, grandparent, brother, sister or your child) 1.

Anemia/Sickle Cell Disease or Trait/Blood disorder 9.

Hepatitis/Liver problems SELF FAMILY   2.

Heart disease   3.

Diabetes (if postpartum and had GDM, the repeat screening)   4.

Hypertension/High cholesterol   5.

Thyroid/Endocrine   6.

Pulmonary Disease   7.


Kidney Disease   8.

Seizure Disorders 10.

Migraine headaches 11.

Cancer 12.

Blood clots in legs or lungs 13.

Mental illness/Emotional disorders 14.

Transfusions of blood or blood products 15.

Birth defects/Genetic problems 16.
Tuberculosis SELF FAMILY               If yes to any of the above, please explain: ________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ C. GYNECOLOGICAL HISTORY 1.
Menstrual history: At what age did you start your period?

________ Do you have monthly menses  Yes  No Flow Description (light, moderate, heavy) ________________ Date of last menstrual period ______________ How many days do you bleed?

________ How often do you have your period?

____________ Are you menopausal?

 Yes  No Any problems with your period?

______________________________________________________________________________ Were you on birth control pills at conception?
 Yes  No Current OB/GYN?

__________________________________________________________________________________________ 2.

Any history of female conditions such as endometriosis, ovarian cysts, chronic pelvic pain, etc.?

___________________________ 3.

Breast problems such as breast lumps, biopsies, surgeries?

_________________________________________________________ 4.

Mammograms done/date ___________________________________________________________________________________ 5.
Date of last Pap test _____________ History of any abnormal Pap tests?

 Yes  No If yes, what was done and in what year?

___________________________________________________________________________________________________ Have you had: HPV testing?

 Yes  No When?

________________ Dexa Scan?

 Yes  No When?

_________________ Colposcopy?

 Yes  No When?

___________________ Colonoscopy?

 Yes  No When?

____________________ LEEP?

 Yes  No When?


______________________ Birth Control methods used in the past?

_______________________________________ Present?

________________________ Hormone replacement therapy?

 Yes  No D. OBSTETRICAL HISTORY 1.

Total pregnancies __________ # Living __________ # Preterm ___________ # Abortion ___________ # Miscarriage __________ 2.
Date of last pregnancy ______________________________________________________________________________________  IF POSTPARTUM, advised to delay future pregnancy for 18 months to 5 years.

E. SEXUAL HISTORY (This section lends itself to being a self [patient completed] or a dialogue with the provider) Are you sexually active?

 Yes  No Insertive: Anal  oral  vaginal  Receptive: Anal  oral  vaginal  Orientation:  Heterosexual  homosexual  Bisexual  Other Do you have pain with sex?
 Yes  No Have you been abused sexually or emotionally, physically?

 Yes  No Have you had a recent change in partner?

 Yes  No 1.

Do you have sex with  Men only  Women only  Both men and women 2.

3.

4.

In the past two months, how many partners have you had sex with?

______ In the past 12 months, how many partners have you had sex with?

_______ Is it possible that any of your sex partners in the past 12 months had sex with someone else while they were still in a sexual relationship with you?
 Yes  No 5.

What do you do to protect yourself from STDs and HIV?

___________________________________________________________ 6.

Do you or your partner use condoms and/or dental dams every time you have vaginal, oral or anal sex?

 Yes  No 7.

Have you ever had an STD?

 Yes  No If yes, which STD and when?

_____________________________________________ 8.

Have any of your partners had an STD?


(i.e., chlamydia, gonorrhea, trichomoniasis, herpes, syphilis, hepatitis B, others)  Yes  No If yes, which STD and when?

____________________________________________________________________ 9.

Have you or any of your partners ever injected drugs?

 Yes  No 10.

Have you or any of your partners exchanged money or drugs for sex?

________________________________________________ 11.

Have you had a HIV test?

 Yes  No If so, when?


__________________________________________________________ 12.

Do you wish to have a HIV test today?

 Yes  No RISK FACTORS: Do you have unprotected sex?

 Yes  No Do you have sex with multiple partners?

 Yes  No Occupational?

 Yes  No Drink alcohol, illicit drug use?

 Yes  No Community with high prevalence of STDs?

 Yes  No History of STIs?

 Yes  No Was your birth mother infected?

 Yes  No Early onset of sexual activity?


 Yes  No F. SOCIAL/ENVIRONMENTAL HISTORY 1.

Do you smoke, use smokeless tobacco or use electronic nicotine devices?

2.

Drink alcohol?

3.

Take street drugs?

 Yes  No If yes, how much?

_________ How long?

__________ What?

______________  Yes  No If yes, how much?

_________ How long?

__________ What?

______________  Yes  No If yes, how much?

_________ How long?

__________ What?

______________ What type of street drugs?


__________________________________________________________________________________ 4.

Are you regularly around someone else who uses alcohol, tobacco, electronic nicotine devices or street drugs?

 Yes  No If yes, how much?

______________________ How long?

_________________ G. MENTAL HEALTH HISTORY 1.

During the past two weeks, have you often been bothered by either of the following two problems?

a.
a.

Feeling down, depressed, irritable or hopeless  Yes  No or b.

Little interest or pleasure in doing things  Yes  No In the past year, have you been slapped, kicked or otherwise physically hurt by someone?

 Yes  No 2.

Are you in a relationship with a person who threatens or physically hurts you?

 Yes  No 3.

Have you ever had counseling?

 Yes  No If yes, where?

_______________________________________________________ Have you been on medication in the past?
 Yes  No Were you given Daymark information?
 Yes  No Interviewer’s Signature: ________________________________________________________________ Date: ________________ Signature of Interpreter (if used): ________________________________________________________ Date: ________________ H. IMMUNIZATION ASSESSMENT PER CDC ACIP GUIDELINES (UTD = UP-TO-DATE; REF = referred, and NA = not applicable) Td/Tdap  UTD  REF  NA Hepatitis B  UTD  REF  NA MMR  UTD  REF  NA Meningococcal  UTD  REF  NA Varicella  UTD  REF  NA Pneumonia  UTD  REF  NA HPV  UTD  REF  NA Influenza  UTD  REF  NA Hepatitis A  UTD  REF  NA Source of Information:  NCIR  Patient  Other Written Documentation FOR STAFF USE ONLY  Would Quit SMOKING: Cessation Counseling  Refer to stop smoking clinic  Smoking cessation assistance (quit paper?)
 Negotiate day of cessation  Referral to cessation counselor advisor  Seen smoking by cessation counselor  Smoking cessation program start date ______________ ALCOHOL: Status: Social Drinker Beer Liquor Wine N/A