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PATIENT INTAKE HISTORY

Please fill out the following form to help us understand your physical condition.

First Name

Last Name

Date of Birth

Social Security #

Address

City

State

Zip Code

Primary Phone

Employer

Insurance

Name You Would Like Us to Use

Name of Spouse/Partner

Emergency Contact

Emergency Contact Relationship

Emergency Contact Phone #

Referred By:

Why have you come to the office today?

If you are here for an annual examination is this a:

Primary Care Visit

Gynecology Only

Is this a new problem?

Yes

No

Please describe your problem, including where it is, how severe it is, and how long it's lasted

GYNECOLOGIC HISTORY

FIRST DAY OF LAST NORMAL MENSTRUAL PERIOD:

AGE PERIODS BEGAN:

ANY RECENT CHANGES IN PERIODS?

NUMBER OF SEXUAL PARTNERS (LIFETIME)

NUMBER OF DAYS BETWEEN PERIODS

ARE YOU CURRENTLY SEXUALLY ACTIVE?

SEXUAL PARTNERS ARE

MEN

WOMEN

BOTH

PRESENT METHOD OF BIRTH CONTROL

HAVE YOU EVER USED AN INTRAUTERINE DEVICE (IUD) OR BIRTH CONTROL PILLS?

YES

NO

IF YES, FOR HOW LONG?

WHEN WAS YOUR LAST PAP TEST?

WHAT WAS THE RESULT?

HAVE YOU EVER HAD AN ABNORMAL PAP TEST?

YES

NO

DO YOU DO REGULAR BREAST SELF-EXAMINATIONS?

YES

NO

OBSTETRIC HISTORY

NUMBER OF PREGNANCIES

NUMBER OF ABORTIONS

NUMBER OF MISCARRIAGES

NUMBER OF PREMATURE BIRTHS (<37 weeks)

NUMBER OF LIVE BIRTHS

NUMBER OF LIVING CHILDREN

List each child's birth date, weight at birth, baby's sex, weeks pregnant, type of delivery vaginal, cesarean, etc), and any complications.

CURRENT MEDICATIONS

(Include hormones, vitamins, herbs, nonprescription medications)

LIST ALL MEDICATIONS BELOW - Include drug name, dosage, and doctor who prescribed

FAMILY HISTORY

Mother:

Living

Deceased

If living, provide age

If deceased, cause of death

Father:

Living

Deceased

If living, provide age

If deceased, cause of death

Siblings:

Number living

Number Deceased

Cause(s) of death/Ages

Children:

Number living

Number Deceased

Cause(s) of death/Ages

ILLNESS

DIABETES

YES

NO

STROKE

YES

NO

HEART DISEASE

YES

NO

BLOOD CLOTS IN LUNGS OR LEGS

YES

NO

HIGH BLOOD PRESSURE

YES

NO

HIGH CHOLESTEROL

YES

NO

OSTEOPOROSIS

YES

NO

HEPATITIS

YES

NO

HIV/AIDS

YES

NO

TUBERCULOSIS

YES

NO

BIRTH DEFECTS

YES

NO

DRINKING OR DRUG PROBLEM

YES

NO

BREAST CANCER

YES

NO

COLON CANCER

YES

NO

OVARIAN CANCER

YES

NO

UTERINE CANCER

YES

NO

MENTAL ILLNESS/DEPRESSION

YES

NO

ALZHEIMER'S DISEASE

YES

NO

OTHER

YES

NO

WHICH RELATIVE & AGE OF ONSET

IF YES, LIST RELATIVE AND AGE OF ONSET

SOCIAL HISTORY

EVER SMOKED?

YES

NO

IF YES, LIST PACKS PER DAY AND NUMBER OF YEARS SMOKED

ALCOHOL

YES

NO

IF YES, HOW MANY DRINKS PER DAY/PER WEEK?

RECREATIONAL DRUG USE

YES

NO

SEAT BELT USE

YES

NO

REGULAR EXERCISE

YES

NO

IF YES, HOW LONG AND HOW OFTEN?

DAIRY PRODUCT INTAKE/CALCIUM SUPPLEMENTS

YES

NO

IF YES, LIST DAILY QUANTITY

HEALTH HAZARDS AT HOME OR WORK?

YES

NO

HAVE YOU BEEN SEXUALLY ABUSED, THREATENED OR HURT BY ANYONE?

YES

NO

PERSONAL PROFILE

SEXUAL ORIENTATION

HETEROSEXUAL

HOMOSEXUAL

BISEXUAL

OTHER

MARITAL STATUS

MARRIED

LIVING WITH PARTNER

SINGLE

WIDOWED

DIVORCED

NUMBER OF LIVING CHILDREN

NUMBER OF PEOPLE IN HOUSEHOLD

HIGHEST LEVEL OF EDUCATION COMPLETED

HIGH SCHOOL

SOME COLLEGE/AA DEGREE

COLLEGE DEGREE

GRADUATE DEGREE

OTHER

CURRENT OR MOST RECENT JOB

TRAVEL OUTSIDE THE US?

YES

NO

IF YES, LIST LOCATION(S)

PERSONAL PAST HISTORY OF ILLNESS

ASTHMA

YES

NO

NOT SURE

KIDNEY INFECTIONS/STONES

YES

NO

NOT SURE

SEXUALLY TRANSMITTED DISEASE

YES

NO

NOT SURE

HEART ATTACK/PROBLEMS

YES

NO

NOT SURE

HIGH BLOOD PRESSURE

YES

NO

NOT SURE

RHEUMATIC FEVER

YES

NO

NOT SURE

EATING DISORDER

YES

NO

NOT SURE

CHICKENPOX

YES

NO

NOT SURE

REFLUX/HIATAL HERNIA/ULCERS

YES

NO

NOT SURE

ANEMIA

YES

NO

NOT SURE

SEIZURES/CONVULSIONS/EPILEPSY

YES

NO

NOT SURE

GLAUCOMA

YES

NO

NOT SURE

ARTHRITIS/JOINT PAIN/BACK PROBLEMS

YES

NO

NOT SURE

HEPATITIS/YELLOW JAUNDICE/LIVER DISEASE

YES

NO

NOT SURE

GALLBLADDER DISEASE

YES

NO

NOT SURE

PNEUMONIA/LUNG DISEASE

YES

NO

NOT SURE

TUBERCULOSIS

YES

NO

NOT SURE

HIV/AIDS

YES

NO

NOT SURE

DIABETES

YES

NO

NOT SURE

STROKE

YES

NO

NOT SURE

BLOOD CLOTS IN LUNGS OR LEGS

YES

NO

NOT SURE

COLLAGEN VASCULAR DISEASE (LUPUS)

YES

NO

NOT SURE

CANCER

YES

NO

NOT SURE

DEPRESSION/ANXIETY

YES

NO

NOT SURE

BLOOD TRANSFUSIONS

YES

NO

NOT SURE

BOWEL PROBLEMS

YES

NO

NOT SURE

CATARACTS

YES

NO

NOT SURE

BROKEN BONES

YES

NO

NOT SURE

THYROID DISEASE

YES

NO

NOT SURE

HEADACHES

YES

NO

NOT SURE

OTHER

OPERATIONS/HOSPITALIZATIONS

LIST ALL PROCEDURES, DATE OF PROCEDURE AND HOSPITAL

INJURIES/ILLNESSES

LIST TYPE OF INJURY/ILLNESS AND DATE IT OCCURRED

IMMUNIZATIONS/TEST

TETANUS-DIPHTHERIA BOOSTER

HEPATITIS A VACCINE

VARICELLA VACCINE

INFLUENZA VACCINE (Flu Shot)

HEPATITIS B VACCINE

PNEUMOCOCCAL VACCINE

MEASLES-MUMPS-RUBELLA (MMR) VACCINE

TUBERCULOSIS (TB) SKIN TEST:

RESULT

REVIEW OF SYSTEMS

PLEASE SELCT ANY OF THE FOLLOWING SYMPTOMS THAT APPLY TO YOU NOW OR SINCE ADULTHOOOD

WEIGHT LOSS

NOW

PAST

NOT SURE

WEIGHT GAIN

YES

NO

NOT SURE

FEVER

YES

NO

NOT SURE

FATIGUE

YES

NO

NOT SURE

CHANGE IN HEIGHT

YES

NO

NOT SURE

I declare that the information I’ve provided is accurate & complete

Initials

Today's Date

Thanks for submitting!

If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse.

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