Patient Name:
Answer
Date Of Birth:
Answer
Reason for Visit:
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Who is your Ob/Gyn?
Name
Answer
Phone
Answer
Address
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When was then last you visited your Ob/Gyn?
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Who is your Primary Care Physician?
Name
Answer
Phone
Answer
When was then last you visited your Primary Care Physician?
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How did you hear about us?
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What is your Ancestry / Ethnic Background?
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Have you served as an egg donor, sperm or gestational carrier/surrogate before?
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If so, how many times?
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When was the first day of your last period?
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Are your periods regular or irregular?
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How often do you get your periods?
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How many days of bleeding do you experience?
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Have there been recent changes in your menstrual patterns?
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Do you have pain with menstruation?
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Do you experience pain with sexual intercourse?
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Do you experience pain with ovulation?
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Date of your last Pap smear?
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Did you ever have an abnormal Pap smear?
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When?
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Have you ever had a sexually transmitted disease?
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If so, when?
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Have you ever had Pelvic Inflammatory Disease (PID)?
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If so, when?
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Have you ever used Oral Contraceptive Pills?
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What type/brand?
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Did you have any side effects/reactions?
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How many years?
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When did you last use the pils?
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| Date of Procedure | Date of Procedure | Date of Procedure |
|---|---|---|
| Answer | Answer | Answer |
| Answer | Answer | Answer |
| Medical Disease | History | Comments |
|---|---|---|
| Answer | Answer | Answer |
| Answer | Answer | Answer |
| Medication | Dose | Frequency |
|---|---|---|
| Answer | Answer | Answer |
| Answer | Answer | Answer |
Are you allergic to any medication?
Answer
| Medication | Reaction to the Medication |
|---|---|
| Answer | Answer |
| Answer | Answer |
| Procedure | Date | Outcome/Complications |
|---|---|---|
| Answer | Answer | Answer |
| Answer | Answer | Answer |
Have you ever experienced any complications due to anasthesia?
Answer
Have you ever been pregnant before?
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Date
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Current/Prior Partner
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Live Birth
Answer
Miscarriage/Abortion/Ectopic
Answer
Weeks
Answer
Fetal Heart
Answer
D&C
Answer
| Natural or C-Section | Sex | Wt |
|---|---|---|
| Answer | Answer | Answer |
| Answer | Answer | Answer |
| Family History | History | Outcome/Complications |
|---|---|---|
| Answer | Answer | Answer |
| Answer | Answer | Answer |
Do you use tobacco?
Answer
#Packs/day
Answer
Have you ever used tobacco before?
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Years
Answer
Do you use alcohol?
Answer
#Drinks/wk
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Do you use recreational/street drugs?
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If so, what type and how often?
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Do you use caffeine?
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What Type?
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#Drinks/day
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Do you exercise regularly?
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What type of exersize do you do?
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What is your occupation?
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On a scale of 1-10 (10 being the worst), estimate the level of stress you feel due to your job.
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Are you married?
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Are you currently sexually active?
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How many sexual partners have you had in the past years?
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Do you have any tattos?
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Please list the location on your body and the year you were tattooed
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Do you have any piercings?
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Please list the location on your body and the year you were pierced
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Are there any other aspects of your medical, surgical, family and/or social history that you thinks your doctor should know?
Answer
Comments
Answer
