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VDH GEN HX 2024-12-30 Page 1 of 2 GENERAL HEALTH HISTORY Instructions: Complete at initial visit and review annually. Complete again every 3 years. Date: SECTION 1. BASIC INFORMATION 1. Preferred Name: Pronouns: ☐ He/him ☐ She/her ☐ They/them ☐ 2. What is your gender? ☐Male ☐ Female ☐ Transgender Male (FtM) ☐ Transgender Female (MtF) ☐ Non-binary/Non-conforming ☐ Not 3. What sex were you assigned at birth? ☐ Male ☐ Female ☐ Intersex ☐ Not 4. Country of birth: Primary language: SECTION 2. MEDICAL HISTORY - OFFICE USE ONLY - Check below if you or a family member have any of the following conditions: Date and initial each entry You Family You Family 1. Allergies (food/insects/drugs/latex) ☐ ☐ 13. High blood pressure ☐ ☐ 2. Anemia (low iron) ☐ ☐ 14. Intellectual disability or learning problem ☐ ☐ 3. Asthma / respiratory problems ☐ ☐ 4. Autoimmune disorder (lupus, rheumatoid arthritis, celiac, Crohn’s, ulcerative colitis, etc.) ☐ ☐ 15. Kidney or bladder problems ☐ ☐ 16. Liver disease ☐ ☐ 5. Blood clots (legs or lungs) ☐ ☐ 17. Mental health issues (depression, anxiety, etc.) ☐ ☐ 6. Blood disease / bleeding problem ☐ ☐ 7. Cancer ☐ ☐ 18. Migraines / headaches ☐ ☐ a. Breast Cancer ☐ ☐ 19. Osteoporosis / osteopenia ☐ ☐ b. Ovarian Cancer ☐ ☐ 20. Seizures / epilepsy ☐ ☐ c. Cervical Cancer ☐ ☐ 21. Skin problems ☐ ☐ d. Colon Cancer ☐ ☐ 22. Sickle cell trait or disease ☐ ☐ e. Prostate Cancer ☐ ☐ 23. Stomach or bowel problems ☐ ☐ 8. Diabetes (sugar) ☐ ☐ 24. Stroke ☐ ☐ 9. G6PD deficiency ☐ ☐ 25. Thyroid problems ☐ ☐ 10. Heart problems / murmurs ☐ ☐ 26. Tuberculosis / lung problem ☐ ☐ 11. Hepatitis (virus) infection ☐ ☐ 27. Vision / eye problems ☐ ☐ 12. HIV infection ☐ ☐ 28. Other: ☐ ☐ 29. If male, have you had a vasectomy? ☐ Yes ☐ No ☐ Not applicable 30. Who is your primary care doctor? ☐ None 31.Have you ever been hospitalized? ☐ Yes ☐ No If yes, list dates and why: 32.Have you ever had surgery? ☐ Yes ☐ No If yes, list dates and why: - OFFICE USE ONLY - LABEL ☐ Interpreter or assistive services used ☐ Declined Name: Title: Number: ---PAGE BREAK--- VDH GEN HX 2024-12-30 Page 2 of 2 Date: SECTION 3. INFECTION & IMMUNIZATION HISTORY - OFFICE USE ONLY - 1. Have you ever been diagnosed with the following infections or conditions? Check all that apply Date and initial each entry ☐ Gonorrhea ☐ Herpes ☐ Pelvic inflammatory disease (PID) ☐ Chlamydia ☐ Genital warts (or HPV) ☐ Non-gonococcal urethritis (NGU) ☐ Syphilis ☐ Trichomonas (trich) ☐ Mpox ☐ Other: 2. Did you receive a blood transfusion, blood products, or organ donation before 1992? Or clotting factors prior to 1987? ☐ Yes ☐ No ☐ Unsure 3. Have you received any of the following vaccinations? Check all that apply ☐ Don’t know ☐ HPV ☐ Hepatitis B ☐ Hepatitis A ☐ Mpox ☐ Meningococcal (MenACWY) SECTION 4. SOCIAL HISTORY - OFFICE USE ONLY - Do you currently use, or have you ever used, any of the following substances? Date and initial each entry 1. Cigarettes/tobacco/vaping ☐ Never ☐ Yes, in lifetime ☐ Yes, currently 2. Alcohol/beer/wine/liquor ☐ Never ☐ Yes, in lifetime ☐ Yes, currently 3. Any other substances or drugs ☐ Never ☐ Yes, in lifetime ☐ Yes, currently If yes, please describe: SECTION 5. REPRODUCTIVE HISTORY (IF ASSIGNED FEMALE AT BIRTH) - OFFICE USE ONLY - 1. At what age did your period start? 2. Do you ever miss a period? ☐ Yes ☐ No Have you gone through menopause? ☐ Yes ☐ No 3. How often do you have a period? How long do your periods last? 4. On your heaviest day, how many pads or tampons do you use per day? 5. Do you have period-related problems (cramps, mood swings, swelling)? ☐ Yes ☐ No 6. When was your last PAP smear or HPV test? 7. Have you ever had an abnormal PAP smear or HPV test? ☐ Yes ☐ No If yes, what kind of treatment did you receive? (check all that apply) ☐ Repeat PAP ☐ Colpo (date): ☐ LEEP ☐ Don’t know ☐ None 8. Have you had your tubes tied, uterus removed, or Essure? ☐ Yes ☐ No 9. Have you ever been pregnant? ☐ Yes ☐ No If no, skip remaining questions 10. When was your last pregnancy? How many times have you been pregnant? How many resulted in live birth: miscarriage: termination: stillbirth: 11. Have you ever had a C-section delivery? ☐ Yes ☐ No If yes, how many C-sections? 12. Are you currently breastfeeding/chestfeeding (nursing) or pumping? ☐ Yes ☐ No 13. Have you ever had gestational diabetes during pregnancy? ☐ Yes ☐ No 14. Have you ever had high blood pressure during pregnancy? ☐ Yes ☐ No 15. Have you ever had other pregnancy-related complications? ☐ Yes ☐ No If yes, please describe complications: Date and initial each entry - OFFICE USE ONLY - LABEL Review Date: Initials: ☐ Changes noted Review Date: Initials: ☐ Changes noted Review Date: Initials: ☐ Changes noted Review Date: Initials: ☐ Changes noted