Patient Name Date
DOB Height Weight
REASON FOR VISIT
Why are you seeing the doctor today? ______Have you been treated for this problem in the past? Yes No If yes, please explain ______
Have you had any recent radiology or laboratory studies? Yes No If yes, please indicate where, when, and type of study ______
PAST GYNECOLOGIC HISTORY Please indicate if you have received treatment for the conditions below, or if you are currently receiving treatment.
Yes No Yes No Abnormal Pap HPV (Human Papillomavirus)
Other Gynecologic Problems ______Are there any other medical problems that we should be aware of? ______
Are you currently pregnant or could you possibly be pregnant? Yes No Date of Last Menstrual Period ______/ /
Do you/have you taken female hormones? Yes No
Oral contraceptives? Yes No Type of contraception: ______
Total number of: Pregnancies ______Term Births ______Pre-Term Births ______Elective Abortions ______
Miscarriages ______C-sections ______
REVIEW OF SYSTEMS Do you CURRENTLY have any problems related to the following systems? General Colorectal Cardiovascular Skin Fever Hemorrhoids Chest Pain Rashes Weight Change Anal Fistula Palpitations Lumps Hormonal Problems Psychological Fluid/swollen Extremites Musculoskeletal Joint Pain Anxiety Gynecology Joint Pain Pain in Limbs Depression Abnormal Pap Bone Pain Gastrointestinal Neurological Breast Lump/Pain Muscle Spasm Heartburn Headaches Change in Menses Loss of Function Diarrhea/Constipation Numbness HPV (Human Papillomavirus) Muscle Aches Abdominal Pain Tingling Painful Intercourse Fractured / Broken Bone Nausea/Vomiting Seizures STD (Sexually Transmitted Disease) Trouble Swallowing Weakness Vaginal Discharge GI Bleed Vaginal Dryness REVIEW OF SYSTEMS
REVIEW OF SYSTEMS (CONTINUED) Do you CURRENTLY have any problems related to the following systems?
Eyes Urological Ears, Nose, Throat Respiratory Hematological/lymphatic Glasses/contacts Blood in Urine Dificult Swollowing Shortness of Breath Anemia Cataracts Erectile Dysfunction Ear Pain Sleep Apnea Bleeding Problems Glaucoma Painful Urination Seasonal Allergies Wheezing Clotting Disorder Eye Injury Frequent Urination Hard of Hearing Cough Lymph Problems Incontinence Large Lymph Gland
Patient Name Date
Signature of Patient / Guardian Date
FOR OFFICE USE
Reviewed By Date