(713) 935-9791

929 Gessner Road, Suite 2150, Houston, TX 77024

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Home
About
Our Doctors
Services
Resources
- Patient Forms
- Website Links and Booklets
Contact Us

Medical History

Name(Required)

Date of Birth(Required)

Marital Status(Required)

Single

Married

Separated

Widowed

Referred By:(Required)

Pharmacy Name(Required)

Pharmacy Phone(Required)

Medical History(Required)

Have you ever had any of the following?

None

Anemia

Heart Disease/Attack

Stroke

High Cholesterol

Mitral Valve Prolapse

Bleeding Problems

Breast Cancer

Blood Clots in Lungs/Legs

Gall Bladder Disease

Live Disease/Hepatitis

Kidney Infections

Bladder Infections

Pelvic Infections

Arthritis

Ovarian Cancer

Ovarian Cyst

Chicken Pox

Epilepsy/Seizures

Migraines

Depression/Anxiety

Drug or Alcohol Problems

Diabetes

Colon Cancer

Pneumonia

Tuberculosis

Sickle Cell Disease

Thyroid Problem

Blood Transfusion

Genetic Condition

Asthma

Other

Medications & Doses(Required)

List all medications & dose you are currently taking, including over-the-counter medications, vitamins and herbal remedies:

Allergies(Required)

I'm Allergic to Some Medication

No Known Allergies

Allergies Description(Required)

List any Allergies to Medication

Reactions(Required)

List any Reactions to Medication

Surgical History

Date

Surgery

Date

Surgery

Date

Surgery

Date

Surgery

Obstetrical History

I have...(Required)

Never Been Pregnant

Adopted Children

None of the Above

Pregnancy History

Please list all pregnancies in order, including miscarriages, premature births, stillbirths, ectopics (tubal) and abortions:

Year(Required)

Male/Female(Required)

Infant's Weight(Required)

Gestional Age of Delivery(Required)

Delivering Doctor(Required)

Problems(Required)

Add Pregnancy? (2)

Yes

No

Year(Required)

Male/Female(Required)

Infant's Weight(Required)

Gestional Age of Delivery(Required)

Delivering Doctor(Required)

Problems(Required)

Add Pregnancy? (3)

Yes

No

Year(Required)

Male/Female(Required)

Infant's Weight(Required)

Gestional Age of Delivery(Required)

Delivering Doctor(Required)

Problems(Required)

Add Pregnancy? (4)

Yes

No

Year(Required)

Male/Female(Required)

Infant's Weight(Required)

Gestional Age of Delivery(Required)

Delivering Doctor(Required)

Problems(Required)

Add Pregnancy? (5)

Yes

No

Year(Required)

Male/Female(Required)

Infant's Weight(Required)

Gestional Age of Delivery(Required)

Delivering Doctor(Required)

Problems(Required)

Gyn History

Last Mestrual Period:(Required)

Age of first period:(Required)

Cycle Length:(Required)

Lasting:(Required)

1-3 days

4-6 days

7-9 days

None

Periods are:(Required)

Regular

Irregular

Painful (cramping/aching)

Not really bothersome

Flow is:(Required)

Light

Light to moderate

Moderate to heavy

Very heavy

Menopause Date(Required)

If it applies

Hysterectomy (Date)(Required)

If it applies

Are you sexually active?(Required)

Yes

No

Virginal

Family History

Please list any close relatives with history of the following: Please list Relationship/Age at Diagnosis/Status

Breast Cancer(Required)

Ovarian Cancer(Required)

Colon Cancer(Required)

Uterine Cancer(Required)

Diabetes(Required)

Heart Disease(Required)

Heart attack, stroke, bypass surgery.

Social History

Alcohol Use(Required)

Yes

No

If yes, how many drinks per day/month:(Required)

Tobacco Use(Required)

Yes

No

If yes, how many packs a day and how long have you been smoking?(Required)

Street drug use(Required)

Yes

No

Street drug type and frequency(Required)

Excercise(Required)

Yes

No

Exercise type and frequency(Required)

Caffeine(Required)

Yes

No

If yes, how many caffeinated drinks per day/week?(Required)

Coffee, tea, soda.

Sexual Abuse(Required)

Yes

No

If yes, are you safe now?(Required)

Yes

No

Have you received counseling?(Required)

Yes

No

Physical Abuse(Required)

Yes

No

If yes, are you safe now?(Required)

Yes

No

Have you received counseling?(Required)

Yes

No

Emotional Abuse(Required)

Yes

No

If yes, are you safe now?(Required)

Yes

No

Have you received counseling?(Required)

Yes

No

Signature(Required)

Date Signed(Required)

Quick Contact

Office : 713-935-9791
Fax : 713-467-9709
Email :[email protected]

Office Hours

Monday–Thursday:
8:00am - 5:00pm

Friday:
8:00am - 12:00pm

Quick Links

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Location

929 Gessner Road, Suite 2150
Houston, TX 77024