Gynecology Intake Form

Gynecology Intake Form

Lystra Wilson-Celestine, MD/MPH
Patient Name

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Marital Status
Occupation
For how long?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearPlease enter the date closest to when you started your occupation.
Reason for this Visit:
How did you hear about us? If referred by a Physician, who?

Referred by Physician
Menstrual History

(Please complete all that may apply to you)
If you are Post-Menopausal (12mths without a period) please indicate the year of your last period?
Have you experienced any Post-Menopausal bleeding
Give date of last Post-Menopausal bleed
Have you ever used Hormone Replacement Therapy
What type of Hormone Replacement Therapy have you used in the past? Check all that applies

Other
What side effects have you had from any HRT used in the past? Answer if applicable.
Age of first period?
If your Menstrual periods are REGULAR (your period starts around the same day every month);
Your period starts every ex. 28days.

If your Menstrual periods are IRREGULAR (your period is random and not consistent every month);
Your period starts every ex. 12 to ex. 60 days.
Duration of bleeding? (Please indicate whether the numeric value coordinates with days, months, years, etc.)
Does bleeding or spotting occur between periods?
Does bleeding or spotting occur after intercourse?
If your are regularly having periods, what was the first day of last known menstrual period?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is pain associated with your period?
If yes, is it:
Please fill out the following chart related to ALL previous pregnancies and obstetrical history, including, miscarriages, abortions & ectopic (tubal) pregnancies.

(If applicable, please leave blank if you have never been pregnant)

Rows	Date of Birth	Child Sex (M/F)	Place of Delivery	Birth Weight	Pregnancy Duration (Specify weeks/months)	Type of Delivery (if applicable)	Noted Complications Mother and/or Infant
First Pregnancy
Second Pregnancy
Third Pregnancy
Fourth Pregnancy
Fifth Pregnancy
Sixth Pregnancy

Birth Control History
What Birth control method(s) do you currently use? (Check all that apply)

Other
Brand (If applicable)
ParaGard®, Kyleena®, Depo-Provera, Ortho Tri-Cyclen, etc.
How long have you been using this method?
Sexual History
Are you sexually active?
My sexual partner is:
What is your sexual identity?
lesbian, gay, bisexual, transgender, etc.
Past Medical History

Other
Do you suffer from vaginal dryness and/or painful intercourse?
Past Obstetrical/ Gynecological Surgeries (Check all that apply)

Leave blank if none
Surgery

Other (please specify)
If yes, please specify the surgery performed and year of surgery
Past Surgical History (Not OB/GYN)

Leave blank if none

List ALL surgeries and the year performed

Rows	Surgery	Year/Month	Complications
1.
2.
3
4.
5.

Please List Any Allergies To Medications (If None Please Type "None")
Please List Medications
Pap Smear/ Mammogram History
Date of last Pap Smear

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Medical Facility or Provider Name:
Have you ever had an abnormal Pap Smear? If yes, when?
ex. (Yes. 04/2020)
Have you had treatment for an abnormal Pap Smear?

Yes (Please specify treatment/year)
Date of last Mammogram

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Medical Facility or Provider Name:
Have you ever had an abnormal Mammogram? If yes, when?
ex. (Yes. 04/2020)
Have you had treatment for an abnormal Mammogram?

Yes (Please specify treatment/year)
Social History
Please list any substance use: e.g. (smoking, alcohol, marijuana, other drugs)
Lifestyle
Family Medical History

(Please leave blank if you have NO Family History, or if your Family History is unknown)

Please select/ list any that may apply

Rows	Age	Deceased	Affected Relative
Diabetes
Ovarian Cancer
Heart Disease
Endometrial Cancer
Breast Cancer
Colon Cancer
Thyroid Disease
Other (specify below)
Other (specify below)
Other (specify below)

If other is checked above, please specify here.
Type a question
Other Symptoms or Problems

Other (please specify)
Please provide any additional information you would like the doctor to know before your visit?
Have you ever considered or had any aesthetics, such as Botox or Fillers?
If yes, please explain below
Which statement best describes your health goals today
Should be Empty:

Gynecology Intake Form

Menstrual History

Please fill out the following chart related to ALL previous pregnancies and obstetrical history, including, miscarriages, abortions & ectopic (tubal) pregnancies.

Birth Control History

Sexual History

Past Obstetrical/ Gynecological Surgeries (Check all that apply)

Past Surgical History (Not OB/GYN)

Pap Smear/ Mammogram History

Social History

Lifestyle

Family Medical History