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312 707 8988
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SERVICES
FEES & FINANCIAL HELP
HELPFUL INFO
CONTACT US
AREAS WE SERVE
312 707 8988
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Medical History Information

Quality Compassionate Reproductive Health Care Personalized to Fit Your Needs

Why are you asking about my health history before my appointment?

You have been asked to tell us more about your health history because you live more than 2 hours away from our office. It is important for you to answer all of these questions honestly and completely so that we can safely provide you medical care at our clinic.

There are three different ways you can give us your health history information:

You can complete the form below and submit the information through our website
You can click here to open a PDF file, complete the form and then email or fax the form to us
You can call us and answer the questions over the telephone- please note this can take 5-7 minutes and you may have some wait time to speak with a staff member

Form for Online Submission:

What is your patient ID number?*

How old are you?*

What is the zip code where you live?*

What is a good phone number where we can reach you?*

Please answer your phone if you recieve call from an unrecognized phone number with a 312 area code.

Do you want us to call or text you if we have more questions?*

Call Me

Text Me

Call or Text Me

Can we leave a voice mail message?*

YES

Who should we say is calling?*

Family Planning Associates

The Doctor's Office

Your Friend (the staff member will use their first name)

Tell us the first day of your last normal period or about your ultrasound results*

What kind of procedure are you requesting?*

Medication

In-Office Procedure

I am not sure yet

Have you ever been to see a heart or lung doctor?*

YES

DO YOU HAVE ANY OF THE FOLLOWING MEDICAL CONCERNS/CONDITIONS?

If Yes, what did you see the doctor for? Please be as detailed as possible when telling us why you had to see a heart/lung doctor.*

Asthma*

YES

I did when I was younger

If yes, what causes you to have an asthma attack and when did you last use an inhaler?*

High Blood Pressure*

YES

Only during pregnancy

If yes, do you take any medication(s)? What dosage and how often do you take your medications?*

Heart Disease*

YES

If yes, please explain:*

Blood Clot in a Vein*

YES

If yes, please explain:*

Diabetes*

YES

If yes, do you take any medication(s)? What dosage and how often do you take your medications?*

Liver Disease*

YES

If yes, please explain:*

Kidney Problems*

YES

If yes, please explain:*

Bladder Problems*

YES

If yes, please explain:*

Hepatitis*

YES

If yes, please explain:*

Cancer*

YES

If yes, please explain:*

Thyroid Problems*

YES

Have you had thyroid labs with your doctor in the last three months?*

YES

Tuberculosis (TB)*

YES

Bleeding Disorders or Problems*

YES

If yes, please explain:*

Sickle Cell Anemia*

YES

If yes, please explain:*

Anemia*

YES

Seizures*

YES

Only when I was a child

If yes, please explain:*

Headaches*

YES

If yes, please explain:*

Dizziness*

YES

If yes, please explain:*

Vision Problems*

YES

Body and/or Facial Piercing(s)*

YES

Severe Depression*

YES

If yes, please explain:*

Anesthesia Problems*

YES

If yes, please explain:*

Malignant Hyperthermia*

YES

If yes, please explain:*

Has anyone in your immediate family (mother, father, and/or sibling) ever had anesthesia problems?*

YES

If yes, please explain:*

Do you have any allergies?*

YES

What Medication(s), Food(s), and/or Latex Product(s) Have You Had an Allergic Reaction To? What Kind of Reactions(s) Have You Had?*

Have you ever had Pelvic Inflammatory Disease (PID)?*

YES

If yes, when? Please explain what happened:*

Have you ever been told that you have or had a Sexually Transmitted Infection (STI / STD)?*

YES

What year(s) did you have an STI / STD?*

What kind of infection do/did you have?*

Are you finished with your treatment for the infection (STI / STD)?*

YES

No treatment was needed

Do you have any other medical issues or concerns that were not mentioned above?*

YES

If yes, please explain:*

Have you been pregnant before?*

YES

Have you ever had a c-section delivery?*

YES

If Yes, How many and what year(s)?*

Did you have any complications or problems after your c-section(s) - like heavy bleeding (hemorrhage), infection, or additional surgery?*

YES

If yes, please explain:*

Have you ever had a vaginal delivery?*

YES

If Yes, How many and what year(s)?*

Did you personally, have any complications or problems after giving birth -- like heavy bleeding (hemorrhage), infection, or additional surgery?*

YES

If yes, please explain:*

Have you ever had a miscarriage?*

YES

If Yes, How many and what year(s)?*

Did you personally, have any complications or problems after a miscarriage -- like heavy bleeding (hemorrhage), infection, or additional surgery?*

YES

If yes, please explain:*

Have you ever had an abortion?*

YES

If Yes, How many and what year(s)?*

Did you personally, have any complications or problems after a previous abortion -- like heavy bleeding (hemorrhage), infection, or additional surgery?*

YES

If yes, please explain:*

Have you ever had an ectopic pregnancy, outside of the uterus?*

YES

If Yes, How many and what year(s)?*

Did you personally, have any complications or problems after having an ectopic pregnancy -- like heavy bleeding (hemorrhage), infection, or additional surgery?*

YES

If yes, please explain:*

Have you ever had a molar pregnancy? (This is rare)*

YES

If Yes, How many and what year(s)?*

Did you personally, have any complications or problems after having a molar pregnancy -- like heavy bleeding (hemorrhage), infection, or additional surgery?*

YES

If yes, please explain:*

Have you ever had a surgery or been hospitalized overnight?*

YES

If Yes, Please Give Us Some Details (including what kind of surgery / why you were in the hospital and when)*

Have you ever had a serious injury?*

YES

If Yes, Please Give Us Some Details (including what kind of injury and when)*

Have you ever had a bad reaction to anesthesia or any kind of medication?*

YES

If Yes, Please Give Us Some Details (including what happened and when):*

Do you currently see a medical professional for any type of medical problem?*

YES

If Yes, Please Give Us Some Details:*

Do you currently take any prescription medications, herbs, diet pills and/or vitamins?*

YES

If Yes, what do you take (please include the dosage and how often it is taken)?*

Do you use any recreational drugs?*

YES

If Yes, what drug(s) and when was the last time?*

Do you drink alcohol?*

YES

If Yes, how often and how much?*

How tall are you?*

How much do you weigh?*

Thank you for taking the time to give us this important information. If we have any questions one of our staff will contact you. If you have any questions or concerns do not hesitate to contact us at 312-707-8988 or info@fpachicago.com.

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Chicago | Downtown

312-707-8988
659 W. Washington Blvd.
Chicago IL 60661
Fax (312) 707-9223

Frequently Asked Questions

Online Appointment Scheduling

Medical History Information

Quality Compassionate Reproductive Health Care Personalized to Fit Your Needs

Why are you asking about my health history before my appointment?

There are three different ways you can give us your health history information:

You can complete the form below and submit the information through our website
You can click here to open a PDF file, complete the form and then email or fax the form to us
You can call us and answer the questions over the telephone- please note this can take 5-7 minutes and you may have some wait time to speak with a staff member

Form for Online Submission:

What is your patient ID number?*

How old are you?*

What is the zip code where you live?*

What is a good phone number where we can reach you?*

Please answer your phone if you recieve call from an unrecognized phone number with a 312 area code.

Do you want us to call or text you if we have more questions?*

Call Me

Text Me

Call or Text Me

Can we leave a voice mail message?*

YES

Who should we say is calling?*

Family Planning Associates

The Doctor's Office

Your Friend (the staff member will use their first name)

Tell us the first day of your last normal period or about your ultrasound results*

What kind of procedure are you requesting?*

Medication

In-Office Procedure

I am not sure yet

Have you ever been to see a heart or lung doctor?*

YES

DO YOU HAVE ANY OF THE FOLLOWING MEDICAL CONCERNS/CONDITIONS?

If Yes, what did you see the doctor for? Please be as detailed as possible when telling us why you had to see a heart/lung doctor.*

Asthma*

YES

I did when I was younger

If yes, what causes you to have an asthma attack and when did you last use an inhaler?*

High Blood Pressure*

YES

Only during pregnancy

If yes, do you take any medication(s)? What dosage and how often do you take your medications?*

Heart Disease*

YES

If yes, please explain:*

Blood Clot in a Vein*

YES

If yes, please explain:*

Diabetes*

YES

If yes, do you take any medication(s)? What dosage and how often do you take your medications?*

Liver Disease*

YES

If yes, please explain:*

Kidney Problems*

YES

If yes, please explain:*

Bladder Problems*

YES

If yes, please explain:*

Hepatitis*

YES

If yes, please explain:*

Cancer*

YES

If yes, please explain:*

Thyroid Problems*

YES

Have you had thyroid labs with your doctor in the last three months?*

YES

Tuberculosis (TB)*

YES

Bleeding Disorders or Problems*

YES

If yes, please explain:*

Sickle Cell Anemia*

YES

If yes, please explain:*

Anemia*

YES

Seizures*

YES

Only when I was a child

If yes, please explain:*

Headaches*

YES

If yes, please explain:*

Dizziness*

YES

If yes, please explain:*

Vision Problems*

YES

Body and/or Facial Piercing(s)*

YES

Severe Depression*

YES

If yes, please explain:*

Anesthesia Problems*

YES

If yes, please explain:*

Malignant Hyperthermia*

YES

If yes, please explain:*

Has anyone in your immediate family (mother, father, and/or sibling) ever had anesthesia problems?*

YES

If yes, please explain:*

Do you have any allergies?*

YES

What Medication(s), Food(s), and/or Latex Product(s) Have You Had an Allergic Reaction To? What Kind of Reactions(s) Have You Had?*

Have you ever had Pelvic Inflammatory Disease (PID)?*

YES

If yes, when? Please explain what happened:*

Have you ever been told that you have or had a Sexually Transmitted Infection (STI / STD)?*

YES

What year(s) did you have an STI / STD?*

What kind of infection do/did you have?*

Are you finished with your treatment for the infection (STI / STD)?*

YES

No treatment was needed

Do you have any other medical issues or concerns that were not mentioned above?*

YES

If yes, please explain:*

Have you been pregnant before?*

YES

Have you ever had a c-section delivery?*

YES

If Yes, How many and what year(s)?*

Did you have any complications or problems after your c-section(s) - like heavy bleeding (hemorrhage), infection, or additional surgery?*

YES

If yes, please explain:*

Have you ever had a vaginal delivery?*

YES

If Yes, How many and what year(s)?*

Did you personally, have any complications or problems after giving birth -- like heavy bleeding (hemorrhage), infection, or additional surgery?*

YES

If yes, please explain:*

Have you ever had a miscarriage?*

YES

If Yes, How many and what year(s)?*

Did you personally, have any complications or problems after a miscarriage -- like heavy bleeding (hemorrhage), infection, or additional surgery?*

YES

If yes, please explain:*

Have you ever had an abortion?*

YES

If Yes, How many and what year(s)?*

Did you personally, have any complications or problems after a previous abortion -- like heavy bleeding (hemorrhage), infection, or additional surgery?*

YES

If yes, please explain:*

Have you ever had an ectopic pregnancy, outside of the uterus?*

YES

If Yes, How many and what year(s)?*

Did you personally, have any complications or problems after having an ectopic pregnancy -- like heavy bleeding (hemorrhage), infection, or additional surgery?*

YES

If yes, please explain:*

Have you ever had a molar pregnancy? (This is rare)*

YES

If Yes, How many and what year(s)?*

Did you personally, have any complications or problems after having a molar pregnancy -- like heavy bleeding (hemorrhage), infection, or additional surgery?*

YES

If yes, please explain:*

Have you ever had a surgery or been hospitalized overnight?*

YES

If Yes, Please Give Us Some Details (including what kind of surgery / why you were in the hospital and when)*

Have you ever had a serious injury?*

YES

If Yes, Please Give Us Some Details (including what kind of injury and when)*

Have you ever had a bad reaction to anesthesia or any kind of medication?*

YES

If Yes, Please Give Us Some Details (including what happened and when):*

Do you currently see a medical professional for any type of medical problem?*

YES

If Yes, Please Give Us Some Details:*

Do you currently take any prescription medications, herbs, diet pills and/or vitamins?*

YES

If Yes, what do you take (please include the dosage and how often it is taken)?*

Do you use any recreational drugs?*

YES

If Yes, what drug(s) and when was the last time?*

Do you drink alcohol?*

YES

If Yes, how often and how much?*

How tall are you?*

How much do you weigh?*

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© 2018-2024 Family Planning Associates Medical Group, LTD. FPA Chicago abortion clinic serves Illinois and all Chicago Suburbs. Family Planning Associates Medical Group is honored to accept patients from Indiana, Wisconsin, Kentucky, Tennessee, Missouri, Arkansas, Georgia, Florida, Louisiana, Mississippi, Alabama, Texas & Iowa. FPA Offers the medication abortion pill up to 12 weeks & in-clinic surgical abortion with sedation up to 24 weeks.

Call: 312 707 8988
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