Ob Gyn Patient History Form

1
Name
First Name
Last Name
2
Email
example@example.com
3
Phone Number
Please enter a valid phone number.
4
Please indicate your marital status.
Married
Single
In a relationship
5
Please indicate the reason for this visit.
6
Please indicate your occupation.
7
Please indicate your partner's occupation.
8
First Period Date
Date
Month
Day
Year
9
Please indicate your age at first period.
10
Is your period regular?
Yes
No
11
How many days is your period interval?
12
How many days do you bleed?
13
Please indicate the first day of last menstrual period.
Date
Month
Day
Year
14
Do you have pain during your period?
Yes
No
15
Please describe the pain that you have during your period.
16
Please indicate if you... (Do not answer this question if you have been pregnant before.)
Have never been pregnant
17
Please fill in the information below.
Year
Abortion or place of delivery
Duration Pregnancy
Hours of Labor
Type of Delivery
 Delivery Complications Mother and/or Infant
Child 1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Child 2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Child 3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Child 4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Child 5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Child 1
Child 2
Child 3
Child 4
Child 5
Year
Row 0, Column 0
Abortion or place of delivery
Row 0, Column 1
Duration Pregnancy
Row 0, Column 2
Hours of Labor
Row 0, Column 3
Type of Delivery
Row 0, Column 4
 Delivery Complications Mother and/or Infant
Row 0, Column 5
Year
Row 1, Column 0
Abortion or place of delivery
Row 1, Column 1
Duration Pregnancy
Row 1, Column 2
Hours of Labor
Row 1, Column 3
Type of Delivery
Row 1, Column 4
 Delivery Complications Mother and/or Infant
Row 1, Column 5
Year
Row 2, Column 0
Abortion or place of delivery
Row 2, Column 1
Duration Pregnancy
Row 2, Column 2
Hours of Labor
Row 2, Column 3
Type of Delivery
Row 2, Column 4
 Delivery Complications Mother and/or Infant
Row 2, Column 5
Year
Row 3, Column 0
Abortion or place of delivery
Row 3, Column 1
Duration Pregnancy
Row 3, Column 2
Hours of Labor
Row 3, Column 3
Type of Delivery
Row 3, Column 4
 Delivery Complications Mother and/or Infant
Row 3, Column 5
Year
Row 4, Column 0
Abortion or place of delivery
Row 4, Column 1
Duration Pregnancy
Row 4, Column 2
Hours of Labor
Row 4, Column 3
Type of Delivery
Row 4, Column 4
 Delivery Complications Mother and/or Infant
Row 4, Column 5
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Please fill in the information below.
Sex
Birth Weight
Present Health
Child 1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Child 2 
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Child 3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Child 4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Child 5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Child 1
Child 2 
Child 3
Child 4
Child 5
Sex
Row 0, Column 0
Birth Weight
Row 0, Column 1
Present Health
Row 0, Column 2
Sex
Row 1, Column 0
Birth Weight
Row 1, Column 1
Present Health
Row 1, Column 2
Sex
Row 2, Column 0
Birth Weight
Row 2, Column 1
Present Health
Row 2, Column 2
Sex
Row 3, Column 0
Birth Weight
Row 3, Column 1
Present Health
Row 3, Column 2
Sex
Row 4, Column 0
Birth Weight
Row 4, Column 1
Present Health
Row 4, Column 2
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What method(s) of birth control do you now use?
20
Do you have a sexual partner?
Yes
No
21
Your sexual partner(s) is/are...
Female
Male
Both
22
Do you have any issues about your sexual behavior that you'd like to share with your doctor?
Yes
No
23
Please fill in the information below.
Surgery Year
D&C
Row 0, Column 0
Hysteroscopy
Row 1, Column 0
Infertility surgery
Row 2, Column 0
Tuboplasty
Row 3, Column 0
Tubal ligation
Row 4, Column 0
Laparoscopy
Row 5, Column 0
Hysterectomy (vaginal)
Row 6, Column 0
Hysterectomy (abdominal)
Row 7, Column 0
Myomectomy
Row 8, Column 0
ovarian surgery
Row 9, Column 0
L cyst(s) removed ovarian
Row 10, Column 0
R cyst(s) removed ovarian
Row 11, Column 0
L ovary removed
Row 12, Column 0
R ovary removed
Row 13, Column 0
Vaginal or bladder repair for prolapsed or incontinence
Row 14, Column 0
Cesarean section
Row 15, Column 0
D&C
Hysteroscopy
Infertility surgery
Tuboplasty
Tubal ligation
Laparoscopy
Hysterectomy (vaginal)
Hysterectomy (abdominal)
Myomectomy
ovarian surgery
L cyst(s) removed ovarian
R cyst(s) removed ovarian
L ovary removed
R ovary removed
Vaginal or bladder repair for prolapsed or incontinence
Cesarean section
Surgery Year
Row 0, Column 0
Surgery Year
Row 1, Column 0
Surgery Year
Row 2, Column 0
Surgery Year
Row 3, Column 0
Surgery Year
Row 4, Column 0
Surgery Year
Row 5, Column 0
Surgery Year
Row 6, Column 0
Surgery Year
Row 7, Column 0
Surgery Year
Row 8, Column 0
Surgery Year
Row 9, Column 0
Surgery Year
Row 10, Column 0
Surgery Year
Row 11, Column 0
Surgery Year
Row 12, Column 0
Surgery Year
Row 13, Column 0
Surgery Year
Row 14, Column 0
Surgery Year
Row 15, Column 0
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If you want to mention about any other surgery(ies) that you have had before, please indicate here.
25
Date of last pap smear
Date
Month
Day
Year
26
Date of last mammogram:
Date
Month
Day
Year
27
Have you had an abnormal mammogram?
Yes
No
28
Have you had abnormal pap smears?
Yes
No
29
Have you had treatment for abnormal smears?
Yes
No
30
Fill in the information below.
Year
Loop excision (LEEP)
Row 0, Column 0
Cone biopsy
Row 1, Column 0
Laser
Row 2, Column 0
Cryotherapy
Row 3, Column 0
Loop excision (LEEP)
Cone biopsy
Laser
Cryotherapy
Year
Row 0, Column 0
Year
Row 1, Column 0
Year
Row 2, Column 0
Year
Row 3, Column 0
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Check any that apply.
Check Status
Venereal warts
Row 0, Column 0
Herpes – genital
Row 1, Column 0
Syphilis
Row 2, Column 0
Pelvic inflammatory disease
Row 3, Column 0
Endometriosis
Row 4, Column 0
Chlamydia
Row 5, Column 0
Gonorrhea
Row 6, Column 0
Vaginal infections
Row 7, Column 0
Venereal warts
Herpes – genital
Syphilis
Pelvic inflammatory disease
Endometriosis
Chlamydia
Gonorrhea
Vaginal infections
Check Status
Row 0, Column 0
Check Status
Row 1, Column 0
Check Status
Row 2, Column 0
Check Status
Row 3, Column 0
Check Status
Row 4, Column 0
Check Status
Row 5, Column 0
Check Status
Row 6, Column 0
Check Status
Row 7, Column 0
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Check any that apply.
Check Status
Arthritis
Row 0, Column 0
Diabetes
Row 1, Column 0
Diet controlled
Row 2, Column 0
Pill controlled
Row 3, Column 0
Insulin controlled
Row 4, Column 0
High blood pressure
Row 5, Column 0
Heart disease
Row 6, Column 0
Thyroid disease
Row 7, Column 0
Eating Disorder
Row 8, Column 0
Blood Transfusions
Row 9, Column 0
HIV+
Row 10, Column 0
Bronchitis
Row 11, Column 0
Emphysema
Row 12, Column 0
Asthma
Row 13, Column 0
Epilepsy
Row 14, Column 0
Liver Disease (including hepatitis)
Row 15, Column 0
Gallstones
Row 16, Column 0
Kidney Disease
Row 17, Column 0
Arthritis
Diabetes
Diet controlled
Pill controlled
Insulin controlled
High blood pressure
Heart disease
Thyroid disease
Eating Disorder
Blood Transfusions
HIV+
Bronchitis
Emphysema
Asthma
Epilepsy
Liver Disease (including hepatitis)
Gallstones
Kidney Disease
Check Status
Row 0, Column 0
Check Status
Row 1, Column 0
Check Status
Row 2, Column 0
Check Status
Row 3, Column 0
Check Status
Row 4, Column 0
Check Status
Row 5, Column 0
Check Status
Row 6, Column 0
Check Status
Row 7, Column 0
Check Status
Row 8, Column 0
Check Status
Row 9, Column 0
Check Status
Row 10, Column 0
Check Status
Row 11, Column 0
Check Status
Row 12, Column 0
Check Status
Row 13, Column 0
Check Status
Row 14, Column 0
Check Status
Row 15, Column 0
Check Status
Row 16, Column 0
Check Status
Row 17, Column 0
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33
If you have a current medication, please indicate with the details.(doses, frequency etc.)
34
Do you currently...
Check Status
Smoke
Row 0, Column 0
Use Alcohol
Row 1, Column 0
Use illicit drugs
Row 2, Column 0
Exercises
Row 3, Column 0
Drug allergies
Row 4, Column 0
Smoke
Use Alcohol
Use illicit drugs
Exercises
Drug allergies
Check Status
Row 0, Column 0
Check Status
Row 1, Column 0
Check Status
Row 2, Column 0
Check Status
Row 3, Column 0
Check Status
Row 4, Column 0
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Please share the details of the information above. (How frequently you smoke, which type of exercises you do etc.)
36
Check any that apply.
Check Status
Diabetes
Row 0, Column 0
Ovarian Cancer
Row 1, Column 0
Heart Disease
Row 2, Column 0
Endometrial Cancer
Row 3, Column 0
Breast Cancer
Row 4, Column 0
Colon Cancer
Row 5, Column 0
Diabetes
Ovarian Cancer
Heart Disease
Endometrial Cancer
Breast Cancer
Colon Cancer
Check Status
Row 0, Column 0
Check Status
Row 1, Column 0
Check Status
Row 2, Column 0
Check Status
Row 3, Column 0
Check Status
Row 4, Column 0
Check Status
Row 5, Column 0
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37
Please check if you recently have any.
Check Status
Weight loss
Row 0, Column 0
Weight gain
Row 1, Column 0
Change in energy
Row 2, Column 0
Hair growth
Row 3, Column 0
Hair loss
Row 4, Column 0
Change in urinary function
Row 5, Column 0
Hot flushes/flashing
Row 6, Column 0
Breast discharge
Row 7, Column 0
Weight loss
Weight gain
Change in energy
Hair growth
Hair loss
Change in urinary function
Hot flushes/flashing
Breast discharge
Check Status
Row 0, Column 0
Check Status
Row 1, Column 0
Check Status
Row 2, Column 0
Check Status
Row 3, Column 0
Check Status
Row 4, Column 0
Check Status
Row 5, Column 0
Check Status
Row 6, Column 0
Check Status
Row 7, Column 0
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Note: Only fill out this section if you are pregnant or plan to get pregnant soon.
If the answer is NO for the question(s), please do not answer.

Have any of the following happened to you, the baby's father, or anyone in your family:
39
Down Syndrome (Mongolism)? If yes, who?
40
Other Chromosomal abnormality? If yes, specify.
41
Neural tube defect (spina bifida, anencephaly)? If yes, who?
42
Hemophilia or other coagulation abnormality? If yes, who?
43
Muscular Dystrophy? If yes, who?
44
Cystic Fibrosis? If yes, who?
45
If you or the baby's biological father are of Jewish ancestry, have either of you been screened for Tay-Sachs disease?
46
If you or the baby's biological father are of African ancestry, have either of you beenscreened for Sickle cell trait?
47
If you or the baby's biological father are of Italian, Greek, or Mediterranean background, have either of you been tested for B-thalessemia?
48
If you or the baby's biological father are of Philippine or Southeast Asian ancestry, have either of you been tested for A-thalessemia?
49
Patient Signature
Clear
50
Physician Signature
Clear
Should be Empty: