Patient Information
Height (cm): 170
Weight (kg): 80

Referral Information
Reason for Referral: Some reason
Pregnancy History
Total number of pregnancies: 2
Number of vaginal deliveries: 1
Number of C-sections: 1
Number of miscarriages/pregnancy losses/ectopic pregnancies: 3
Number of abortions/pregnancy terminations: 2
Menstrual History
2025-01-03
Number of days between periods: 32
Number of days period lasts: 8
Are patient's periods painful: Yes
Are patient's periods heavy: Yes
Number of pads/tampons used on the heaviest day of period: 3
Gynecologic History
Abnormal pap tests
Fibroids
Endometriosis
Ovarian cysts
Sexually transmitted infection(s)
Gonorrhea; Chlamydia; Herpes; Genital warts; Syphilis; Other
Date of last pap test: 2026-02-28
Patient is sexually active: Yes
With: Both
Form of birth control used: Birth Control pill / patch / ring; Condoms; IUD (hormone); IUD (copper); Pull-out/withdrawal; Calendar / Natural Family Planning; Partner had vasectomy; Permanent tubal sugery; Subdermal implant; None

Medical History
High blood pressure
Diabetes
Blood clots in lungs/legs
Migraine headaches
Liver disease/hepatitis
Osteoporosis
Infertility
Cancer
Type(s): Unknown
Thyroid problems
Asthma
Anxiety/ Depression
Incontinence (urine/stool)
Constipation
Frequent bladder infections
Other: Stuff
Medications
Aspirin
Allergies
Cats
Past Medical History
None
Family History
High blood pressure
Heart Disease/Stroke
Diabetes
Bad reaction to anesthetic
Breast Cancer
Uterine Cancer
Ovarian Cancer
Colon/Bowel Cancer
Other Cancer(s): Unknown
Social History
Smoker: Yes
Number of years: 3
Number of cigarettes per day: 20
Consumes alcohol: Yes
Number of drinks per week on average: 2
Uses recreational and/or street drugs: Yes
Specify: unknown
Consumes caffeine: Yes
Number of cups of coffee/tea/cola per day: 2