Gynecological History:
We want to welcome you to our office and thank you for giving
us this information.
Name: ____________________________________________________
Date of Birth: ___________
SS# ___________________________ Referring Doctor: _____________________________________
Pharmacy: ______________________________ Phone: _____________________________________
Drug Allergies and Reactions: ________________________________________________________
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Current Medications and Dosages: (Please list ALL)
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Surgery or Hospitalizations: (Please provide reasons and dates)
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Family History:
Bleeding
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Liver Disease
Mental Illness
Osteoporosis
Sickle Cell
Genetics Disorders
(Such as Down’s syndrome)
Cystic Fibrosis
NT Defect/Spina Bifida
Anemia
Hepatitis/Liver Disease
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Dad
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Siblings
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Children
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Grandparent
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Medical History (Do YOU have or have YOU had any of these conditions PLEASE
MARK BOX)
HEALTH SCREENING TEST
Last Pap smear: ______________________________ Date and Result: _______________________
Last Mammogram: ___________________________ Date and Result: _______________________
Last Colonoscopy: ___________________________ Date and Result: _______________________
□ Abnormal Pap smear
□ Anemia
□ Anxiety
□ Arthritis/Rheumatism
□ Asthma
□ Blood Transfusions
□ Bruising Easily
□ Cancer
□ Chest Pain
□ Constipation
□ Depression
□ Diabetes
□ Dizziness/fainting
□ Emphysema
□ Fainting
□ Pneumonia
□ Frequent Nosebleeds
□ Gallbladder Disease
□ Gout
□ Hair Loss
□ Headache (all the time)
□ Heart Attack
□ Heart Condition or murmur
□ Heavy/Irregular Periods
□ High Blood Pressure
□ Intestinal problems
□ Irregular heart rate
□ Kidney stones
□ Liver disease or hepatitis
□ Osteoporosis
□ Pelvic/Gynecologic Infections
□ Scarlet Fever
□ Seizures
□ STD’s
□ Shortness of breath
□ Skin problems
□ Stomach Pains
□ Stroke
□ Thyroid Disease
□ Tuberculosis
□ Ulcer
□ Urinary leakage
□ Urinating too much
□ Weight gain
□ Weight Loss
□ Other _______________
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GYNECOLOGIC HISTORY
Total pregnancies _____________ Live Births ____________ Miscarriages/abortions _________
Last Menstrual Period __________ Normal duration of periods ____________________________
Normal time between periods ______________□ Irregular □ Heavy □ Painful
Birth control __________________________________________________________________________
□ I hope to become pregnant sometime in the future.
HABITS AND SOCIAL HISTORY (PLEASE MARK BOX)
□ Smoking: Packs per day _____________________ How long? ____________________________
□ Other tobacco _______________________________How long? ___________________________
□ Alcohol use(amount) ____________________How long ? ___________________________
□ Exercise ____________________________________________________________________________
□ Coffee of other caffeine? Daily amount ______________________________________________
□ Illegal Drug use _____________________________________________________________________
□ Do you have suicidal thoughts? _____________________________________________________
□ Do you feel safe in your home and at work? _________________________________________
□ Are you sexually active? □ Y □ N If yes how many sex partners have you had in the
last 12 months? _______________________________________________________________________
□ Do you have any pain or bleeding during or after intercourse? ________________________