ANDERSON OB/GYN, PLLC
NEW PATIENT QUESTIONNAIRE
Name:____________________________________________________________________ D.O.B.______________ Age: _____
Addresss:________________________________________________________________Phone: __________________________
Were you referred from another physician? __yes __no Name of referring physician_________________
Primary Physician: _________________________________________________
First day of your last menstrual period? ___/___/______ How often do you have periods? _____________
How long do your periods last? ________ At what age did your periods start/stop? ________/_________
Current contraceptive method(s): ___________________________________________________________
Allergies to medications: __yes __no If yes, which medications? __________________________________
Other allergies(latex, foods): ________________________________________________________________
Which response describes your general health? EXCELLENT
GOOD
FAIR
POOR
REASON FOR YOUR VISIT TODAY: _________________________________________________________________________
GENERAL HEALTH
Do you exercise regularly?
__yes __no
Self Breast examination monthly? __yes __no
Do you follow a special diet?
__yes __no If yes, please specify? ________________________________________________
Do you have a problem with any of the following? __Seeing
__Hearing
__Reading
__Moving
__Walking
PLEASE CIRCLE ANY SIGNIFICANT CONDITIONS BELOW THAT YOU CURRENTLY HAVE
CONSTITUTIONAL
Fever
Chills
Night sweats
Hot flashes
Weight changes
Appetite changes
BREAST
breast pain
breast lump
breast discharge
breast swelling
MUSCULOSKELETAL
joint pain
joint swelling
back pain
weakness
difficulty walking
numbness/tingling
CARDIOVASCULAR
Chest pain
Palpitations
Heart condition
High blood pressure
RESPIRATORY
shortness of breath
cough
sputum production
asthma
PSYCHOLOGICAL
Depression
Anxiety
Mood swings
Nervousness
ENDOCRINE
excessive thirst
excessive urination
heat/cold intolerance
diabetes
GASTROINTESTINAL
nausea
vomiting
constipation
diarrhea
Abdominal pain
Bloating/cramping
Food intolerance
Bloody stool
Black, tarry stool
NEUROLOGIC
headaches
seizures
weakness
GENITOURINARY
abnormal bleeding
bleeding between periods
painful periods
irregular periods
bleeding after intercourse
vaginal discharge/odor
Vaginal itching
sores
abnormal growths
pelvic pain
pelvic fullness/pressure
change in sexual desire
change in sex partner
sexual difficulty
SOCIAL HISTORY
Tobacco use
Alcohol use
Drug use
__yes
__yes
__yes
__no
__no
__no
How much?
______packs/day
How much?
______drinks /day
_______________________________________________________________________________
Caffeine use
Sexually active
__yes
__yes
__no
__no
How much?
Patient Signature/Date:
______cups/day
Physician Signature/Date:
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ANDERSON OB/GYN, PLLC
NEW PATIENT QUESTIONNAIRE
OB/GYN HISTORY
Number of pregnancies_____ Number of live births _____ Number of Living Children _____
Number of miscarriages _____ Number of ectopics _____ Number of elective terminations _____
Weight of Largest baby _______________
Age and sex of Living Children: _________________________________________________________________________________
Date of last delivery: ____________ Number of vaginal deliveries: _____ Number of cesarean deliveries _____
Any pregnancy complications? __________________________________________________________________________________
Date of last Pap smear: ________________ Where was last Pap smear done? _____________________________________________
Have you ever had an abnormal Pap smear: __ Yes __ No If yes, when? _______________________________
Was it treated with any of the following?
__Frequent follow-up Pap smears __Colposcopy
__ Biopsy
__Cone biopsy
__Hysterectomy
__ LEEP
__Cryotherapy
Date of last Mammogram: _______________ Where was your last Mammogram done?_____________________________________
Have you ever had chronic pelvic pain? __Yes
Do you have pain now? __Yes
__No
__No If yes, location:_____________________________________________________________
On a scale of 1-10, how do you rate your pain? No pain 1 2 3 4 5 6 7 8 9 10 Worst possible pain
Have you ever had a sexually transmitted infection? __Yes
__No If yes, please list: _____________________________________
Have you ever had pelvic inflammatory disease (PID)? __Yes __No If yes, when: _________________________________________
Are you currently using hormone replacement therapy? __Yes __No If yes, what type: ______________________________________
Are you able to perform normal activities at home? __Yes
__No If no, explain: ________________________________________
Are you currently or have you ever experienced mental, physical, emotional, or sexual abuse? __Yes __No
If yes, please explain: __________________________________________________________________________________________
Do you currently feel safe in your home? __Yes
__No
MEDICATIONS
NAME OF MEDICATION
Patient Signature/Date:
DOSE
WHAT DO YOU TAKE IT FOR?
Physician Signature/Date:
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ANDERSON OB/GYN, PLLC
NEW PATIENT QUESTIONNAIRE
FAMILY AND MEDICAL HISTORY
Is your Mother alive?
__yes
__no
If no, age and cause of death: ________________________________________________
Is your Father alive?
__yes
__no
If no, age and cause of death: ________________________________________________
How many brothers do you have? _____
How many sisters do you have? ______
LIST ALL RELATIVES WHO HAVE HAD A MAJOR ILLNESS (DIABETES, HEART DISEASE, CANCER, HIGH BLOOD PRESSURE…)
RELATION
TYPE OF ILLNESS
AGE AT DIAGNOSIS
LIST ALL MEDICAL PROBLEMS THAT YOU CURRENTLY HAVE OR HAVE HAD
DATE
MEDICAL PROBLEM
PHYSICIAN
LIST ANY SURGERIES THAT YOU HAVE HAD
DATE
Patient Signature/Date:
SURGERY/PROCEDURE
Physician Signature/Date:
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HOSPITAL AND/OR
PHYSICIAN