1
DR. CARA SPEIER/LIFECYCLES OB/GYN PATIENT INTAKE FORM
NAME:
DOB:
REFERRED BY:
WHY DID YOU COME TO THE OFFICE TODAY?
DATE:
AGE:
OB/GYN HISTORY:
FIRST DAY OF LAST MENSTRUAL PERIOD:
AGE PERIODS BEGAN:
MENOPAUSE:
LENGTH OF PERIODS:
NUMBER OF DAYS BETWEEN PERIODS:
ANY RECENT CHANGES IN PERIODS:
ARE YOU SEXUALLY ACTIVE?
NUMBER OF SEXUAL PARTNERS:
SEXUAL PARTNERS ARE MEN, WOMEN, BOTH? (CIRCLE)
PRESENT METHOD OF BIRTH CONTROL: CONDOMS, VASECTOMY, PILLS, IUD, OTHER, NONE?
DATE OF LAST PAP TEST?
RESULT: NORMAL OR ABNORMAL
SURGERY TO CERVIX? YES OR NO
TYPE OF CERVICAL SURGERY: CRYO, LASER, LEEP
HAVE YOU EVER HAD AN ABNORMAL PAP TEST? YES or NO
IF YES, WHEN?
HISTORY OF HPV? YES or NO
HISTORY OF SEXUALLY TRANSMITTED DISEASES?
TYPE?
NUMBER OF TOTAL PREGNANCIES?
LIVE BIRTHS?
VAGINAL DELIVERIES?
CESAREAN SECTIONS?
PRETERM BIRTHS?
ABORTIONS?
MISCARRIAGES?
D&C?
YES or NO
IMMUNIZATIONS:
YES/WHEN or NO (PLEASE INCLUDE DATE)
HEPATITUS B VACCINE
GARDASIL VACCINE (HPV)
RECENT TB TEST
TETANUS
FAMILY HISTORY:
MOTHER’S AGE:
FATHER’S AGE:
SIBLINGS (NUMBER OF):
CHILDREN (NUMBER OF):
FAMILY ILLNESSES:
DIABETES
STROKE/BLOOD CLOTS
HIGH BLOOD PRESSURE
HEART DISEASE/HEART ATTACK
CANCER/TYPE?
BIRTH DEFECTS
LIVING?
LIVING?
# LIVING:
# LIVING:
CAUSE OF DEATH?
CAUSE OF DEATH?
# DECEASED:
# DECEASED:
LIST RELATIVE:
TURN OVER
2
DR. CARA SPEIER/LIFECYCLES OB/GYN PATIENT INTAKE FORM
NAME:
LIST ALL SURGERIES:
DOB:
DATE:
TYPE OF SURGERY:
PAST MEDICAL HISTROY: CHECK
HIGH BLOOD PRESSURE
DIABETES
THYROID DISEASE
ASTHMA
SEIZURES/TREMORS
HEART MURMUR
TAKE ANTIBIOTICS PRIOR TO DENTIST
HEART ATTACK
STROKE
BLOOD CLOTS IN LEG OR LUNG
EXPOSURE TO HEPATITUS
TUBERCULOSIS
EXPOSURE TO HIV
BLOOD TRANSFUSION
YES
HAVE YOU EVER HAD? (PLEASE CHECK)
FATIGUE___
WEIGHT LOSS/GAIN___
FEVER/CHILLS___
LOSS IN HEIGHT___
GLASSES/CONTACTS___
HEADACHES___
SINUSITIS___
CHEST PAIN___
SWELLING IN LEGS___
COUGH___
WHEEZING___
NAUSEA/VOMITING___
DIARRHEA___
BLOOD IN STOOL___
URINARY INCONTINENCE___
# OF TAMPONS PER DAY?___
BLADDER PROBLEM___
# OF PADS PER DAY?___
BLOOD IN URINE___
PAIN WITH PERIODS___
PMS___
OVARIAN CYSTS___
HEAVY PERIODS___
INFERTILITY___
ABNORMAL DISCHARGE___
MUSCLE WEAKNESS___
SKIN RASHES OR SORES___
SKIN CANCER___
LUMPS IN BREASTS___
BREAST DISCHARGE___
SEIZURES___
DEPRESSION___
SUICIDE ATTEMPTS___
HAIR LOSS___
ABNORMAL THIRST___
HOT FLASHES___
INSOMNIA___
MEMORY LOSS___
EASY BRUISING___
EASY BLEEDING___
SOCIAL HISTORY:
TOBACCO:
ALCOHOL:
RECREATIONAL DRUGS:
SIGNED:
DATE:
NO
CHANGE IN VISION___
HERPES___
PALPITATIONS___
SHORTNESS OF BREATH___
CONSTIPATION___
HEMORRHOIDS___
PAIN WITH URINATION___
FULL BLADDER___
PAIN WITH SEX___
FIBROIDS___
BLOOD TRANSFUSIONS___
JOINT OR MUSCLE PAIN___
PAIN IN BREASTS___
DIZZINESS___
ANXIETY___
HEAT/COLD INTOLERANCE___
NIGHT SWEATS___
STD’S ___
LENGTHY HOSPITALIZATIONS
HISTORY OF ABUSE___
PACKS PER DAY?
DRINKS PER WEEK?
TYPE?
DATE: