NEW PATIENT INTAKE FORM
Today’s Date:
Name:
Occupation:
Spouse/Partner:
Non-OB/GYN Primary Doctor:
Reason for Visit:
Medical Allergies/Reactions:
Date of Birth:
Age:
CIRCLE the gender of your partner: Male Female
Referred By:
Current Medications/Dose (including birth control, over the counter medications and supplements):
Menstrual History:
Age at 1st menses:
First day of last menstrual period:
Cycle length
Duration
Irregular periods?
On your heaviest flow, how often do you change your pad/tampon?
For how many days?
CIRCLE which symptoms you have with your period: cramping, pelvic pain, headaches, mood swings/PMS
CIRCLE which symptoms you have between your periods: abnormal bleeding, cramping, pelvic pain
Date of Last Pap:______ __ Mammogram: ____ ____ Colonoscopy: ____ ____ Bone density: ____ ____
Gynecologic History:
Please CIRCLE if you have or have ever had:
 Yeast, Trichomonas, Bacterial Vaginosis (BV)
 Genital Lesions, Genital Herpes, Genital Warts (Condyloma),
 Gonorrhea, Chlamydia, Syphilis, Pelvic Inflammatory Disease (PID), HIV
 Abnormal Pap, Colposcopy, Laser/Cryosurgery/Freezing/Cone Biopsy/LEEP, Cervical Cancer
 Ovarian Cyst
 Uterine Fibroids
 Fibrocystic Breast, Breast Biopsy or Surgery
 Ovarian Cancer, Uterine Cancer, Breast Cancer, Colon Cancer
 Contraception: Had an IUD, Taken Birth Control Pills, Taken Estrogen, Tubal Ligation
 Infertility
 Sexual problems, painful intercourse, lack of sexual desire
 Endometriosis
 D & C, Laparoscopy, Hysterectomy, Bladder Surgery
 Did your mother take Diethylstilbestrol (DES) when pregnant with you? Y N Unknown
General Medical History: Please CIRCLE if you have or have ever had:
 High Blood Pressure, High Cholesterol, Heart Disease, Heart Murmur
 Pneumonia, Asthma, Tuberculosis
 Hepatitis, Gallstones, Colitis, Ulcers
 Recurrent Urinary Infections, Kidney Disease, Kidney Stones
 Diabetes, Thyroid Disease, Skin Disease
 Arthritis, Osteoporosis
 Cancer
 Anemia, Blood Transfusion, Varicose Veins, Blood clot in the leg or lung (DVT or PE)
 Migraines, Seizure, Stroke
If you checked any of the above, or have other significant medical history, please provide date and relevant
comments:
Surgical history: Please list any surgery and date:
NEW PATIENT INTAKE FORM
Family History
 Check if you were adopted and do not know your family history
Please state which relatives have had the following and their age at diagnosis:
Cancer (see attached form)
Thyroid Disease
Heart Attack
Birth Defects
Blood clots or Stroke
Osteoporosis (Brittle Bones)
High Blood Pressure
Diabetes
Health Habits
Sex:
How long with current partner:
Birth Control Method:
Age of 1st intercourse:
Over 3 lifetime partners?
Tobacco: Packs per day:
How Long:
Quit:
Alcohol:
Drinks per week:
Quit:
Drug use:
Quit:
Do you have any objections to blood transfusion?
Caffeine per day:
Sleep concerns?
Stress concerns?
Weight concerns?
What is your exercise regimen?
How would you describe your diet?
If you bike, do you use a helmet?
Do you use a seat belt?
How often do you perform self breast exams?
What is your daily calcium intake (diet and/or supplements)?
What is your daily Vitamin D intake?
Any history of sexual abuse?
Do you feel safe at home/work?
When was your last tetanus shot?
Pregnancy History
List all pregnancies, including miscarriages and/or abortion
Year Duration
Labor
Weight
Sex
Delivery Type
(Mos/Wks)
length
Hospital
Complications
Review of Systems: Please CIRCLE if you currently have any of the below symptoms
 Constitutional: fever, chills, sweats, increase/decrease in weight or appetite, fatigue, malaise
 Cardiovascular: lightheadedness, palpitations, swelling of legs/ankles, chest pain
 Respiratory: cough, sputum, shortness of breath with or without activity
 Intestinal: dyspepsia, nausea, vomiting, change in bowel movements (frequency, size or shape), black
stools, blood in stools, diarrhea, constipation, abdominal pain, jaundice
 Urinary: increased frequency of urination, painful urination, getting out of bed to urinate, loss of urine
with cough or sneeze, blood in the urine, sudden urge to urinate, slow stream, incomplete emptying
 Musculoskeletal: stiff joints, neck pain, back pain
 Skin: rash, new or unusual skin lesion, changed mole
 Breast: lump, nipple discharge, pain
 Neurologic: headaches, seizures
 Pyschologic: anorexia, anxiety, mood swings, depression
 Endocrinology: excessive urination, excessive thirst, fertility issues, temperature intolerance
 Hematology: easy bruising, excessive bleeding from nose/gums/cuts, abnormal lymph nodes
Revised 7/2011