KYOKO OKAMURA, MD, MPH
Obstetrics & Gynecology
New Patient Questionnaire
Today’s date _________________
Name _________________________________________
Age ______________
Primary Care Provider ____________________________ Who referred you, if not PCP? _________________________
Please answer all that apply to you. This form will be added to your medical record.
Reason for today’s visit:
PREGNANCY HISTORY
 No pregnancies
Number of times pregnant _____ Full term births _____ Premature births _____ Elective terminations _____
Miscarriages_____ Ectopic pregnancies _____ Multiple Births (i.e., twins) _____ Adopted children _____
Living Children _____
Please list pregnancies lasting more than 20 weeks:
Date
Length of preg in weeks
Sex & weight
Vaginal or
C-section
Hospital/Doctor
Complications, if any
1)
2)
3)
4)
5)
GYNECOLOGIC HISTORY
Date of last period (1st day) _______
Age at 1st period _______
If applicable,  Menopause  Hysterectomy at what age _______ If so, ever on hormone therapy?
 Yes  No
My period is  regular  irregular, occurs every ____________ days (1st day to 1st day), and lasts for ____________ days
Date of last Pap smear _________________  None
Have you ever had abnormal Pap smears?
 Yes  No
If yes, year and treatment given:________________________
Please check if you have or have had any of the following:
 Painful periods
 Endometriosis
 Infertility
 Recent change in periods
 Fibroids
 Recurrent vaginitis
 Heavy periods
 Ovarian cysts
 DES exposure
 Uterine anomaly (unusually shaped uterus)
Have you had any of the following pelvic infections?
 Yeast
 Gonorrhea
 Herpes
 Genital warts (HPV)
 Bacterial Vaginosis (Gardnerella)
 Chlamydia
 Trichomonas
 Syphilis
 PID (infection in your Fallopian tubes or ovaries)
If yes, please detail year and treatment given: ______________________________________________________________
Are you currently having sex?  Yes  No If yes, with whom and how many?  Men _____ and / or  Women _____
Are you experiencing any problems with sex?  Yes  No __________________________________________________
Number of sexual partner(s) total in your life time ________  Men  Women  Both
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Please check all contraceptive methods you have used in the past:
Have you had any problems with these methods? __________________________________________________________
Are you aware that condoms help prevent sexually transmitted infections?  Yes  No
 Yes  No
MEDICAL PROBLEMS
epsy
SURGICAL HISTORY
Name of procedure
Date of procedure
Reason for procedure
MEDICATIONS including prescription and non-prescription drugs, i.e. vitamins, herbs
Name of drug
Dose
Frequency
Reason for medication
ALLERGIES
Name of drug
Reaction (i.e., hives, rash, shortness of breath)
FAMILY HISTORY
(high blood pressure)
GENERAL HEALTH
Do you / did you ever smoke cigarettes?  Never  Yes, Avg. _____ pack(s)/day for _____ yrs
How much alcohol do you drink/week?
None
Have you used marijuana or other recreational drugs in the last 5 years?  No
 Yes
What do you do for work, if you work? __________________________________
 Quit, when? _______
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Do you exercise?  Yes, Avg. ______times / week  No
Do you wear seatbelt?  Yes  No
Do you have a gun / fire arms in your home?
 Yes  No
Do you take calcium supplements or eat dairy (milk, cheese, yogurt) everyday?  Yes  No
Date of last cholesterol level check ____________________  I have not had a cholesterol check
Date of last colonoscopy ____________________  I have not had a colonoscopy
Date of last bone mineral density check ____________________  I have not had a bone mineral density check
Date/place of most recent mammogram __________________________________
 I have not had a mammogram
If applicable, have you ever had an abnormal mammogram?  Yes  No
Are you immune to
Rubella?
 Yes  No  Not sure
Chicken pox?  Yes  No  Not sure
Hepatitis B?
 Yes  No  Not sure
If a candidate, are you interested in receiving the flu vaccine?  Yes  No  Already vaccinated
If a candidate, are you interested in receiving the HPV vaccine (Gardasil)?  Yes  No  Already vaccinated
Have you had a tetanus diphtheria booster within the last 10 years?
 Yes  No  Not sure
Have you been exposed to people with tuberculosis?  Yes  No  Not sure
Please check (x) if any of the following symptoms apply to you currently.
CONSTITUTIONAL
BREASTS
SKIN
None
EYES, EARS, NOSE, THROAT
HEMATOLOGIC/LYMPHATIC
NEUROLOGIC
RESPIRATORY
GENITOURINARY
MUSCULOSKELETAL
Shortness of breath
PSYHIATRIC
CARDIOVASCULAR
or hopeless
things you used to enjoy
GASTROINTESTINAL
ENDOCRINE
Vomiting
Frequent diarrhea
intolerance
Cold intolerance
urination
stool
Thank you for your cooperation.
Patient signature: __________________________ Date: ______________
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