Ob Gyn Patient History Form

Ob Gyn Patient History Form
Name
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please indicate your marital status.
Please indicate the reason for this visit.
Please indicate your occupation.
Please indicate your partner's occupation.
Menstrual History
First Period Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please indicate your age at first period.
Is your period regular?
How many days is your period interval?
How many days do you bleed?
Please indicate the first day of last menstrual period.
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you have pain during your period?
Please describe the pain that you have during your period.
Pregnancy History
Please indicate if you... (Do not answer this question if you have been pregnant before.)
Please fill in the information below.
Rows Year Abortion or place of delivery Duration
Pregnancy Hours of
Labor Type of
Delivery
Delivery
Complications Mother
and/or Infant
Child 1
Child 2
Child 3
Child 4
Child 5
Please fill in the information below.
Rows Sex Birth
Weight Present
Health
Child 1
Child 2
Child 3
Child 4
Child 5
History of Birth Control
What method(s) of birth control do you now use?
Sexual History
Do you have a sexual partner?
Your sexual partner(s) is/are...
Do you have any issues about your sexual behavior that you'd like to share with your doctor?
Past Obstetrical/Gynecological Surgeries

Please fill in the information below.

Rows	Surgery Year
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

If you want to mention about any other surgery(ies) that you have had before, please indicate here.
Pap Smear/ Mammogram History
Date of last pap smear
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of last mammogram:
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you had an abnormal mammogram?
Have you had abnormal pap smears?
Have you had treatment for abnormal smears?
Fill in the information below.
Rows Year
Loop excision (LEEP)
Cone biopsy
Laser
Cryotherapy
Other Past Gynecological History
Check any that apply.
Rows Check Status
Venereal warts 1
Herpes – genital 2
Syphilis 3
Pelvic inflammatory disease 4
Endometriosis 5
Chlamydia 6
Gonorrhea 7
Vaginal infections 8
Past Medical History

Rows	Year
Loop excision (LEEP)
Cone biopsy
Laser
Cryotherapy

Rows	Check Status
Venereal warts	1
Herpes – genital	2
Syphilis	3
Pelvic inflammatory disease	4
Endometriosis	5
Chlamydia	6
Gonorrhea	7
Vaginal infections	8

Check any that apply.

Rows	Check Status
Arthritis	9
Diabetes	10
Diet controlled	11
Pill controlled	12
Insulin controlled	13
High blood pressure	14
Heart disease	15
Thyroid disease	16
Eating Disorder	17
Blood Transfusions	18
HIV+	19
Bronchitis	20
Emphysema	21
Asthma	22
Epilepsy	23
Liver Disease (including hepatitis)	24
Gallstones	25
Kidney Disease	26

If you have a current medication, please indicate with the details.(doses, frequency etc.)
Do you currently...
Rows Check Status
Smoke 27
Use Alcohol 28
Use illicit drugs 29
Exercises 30
Drug allergies 31
Please share the details of the information above. (How frequently you smoke, which type of exercises you do etc.)
Family History
Check any that apply.
Rows Check Status
Diabetes 32
Ovarian Cancer 33
Heart Disease 34
Endometrial Cancer 35
Breast Cancer 36
Colon Cancer 37
Other Symptoms
Please check if you recently have any.
Rows Check Status
Weight loss 38
Weight gain 39
Change in energy 40
Hair growth 41
Hair loss 42
Change in urinary function 43
Hot flushes/flashing 44
Breast discharge 45
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:
Down Syndrome (Mongolism)? If yes, who?
Other Chromosomal abnormality? If yes, specify.
Neural tube defect (spina bifida, anencephaly)? If yes, who?
Hemophilia or other coagulation abnormality? If yes, who?
Muscular Dystrophy? If yes, who?
Cystic Fibrosis? If yes, who?
If you or the baby's biological father are of Jewish ancestry, have either of you been screened for Tay-Sachs disease?
If you or the baby's biological father are of African ancestry, have either of you beenscreened for Sickle cell trait?
If you or the baby's biological father are of Italian, Greek, or Mediterranean background, have either of you been tested for B-thalessemia?
If you or the baby's biological father are of Philippine or Southeast Asian ancestry, have either of you been tested for A-thalessemia?
Patient Signature
Clear
Physician Signature
Clear
Should be Empty:

Rows	Check Status
Smoke	27
Use Alcohol	28
Use illicit drugs	29
Exercises	30
Drug allergies	31

Rows	Check Status
Diabetes	32
Ovarian Cancer	33
Heart Disease	34
Endometrial Cancer	35
Breast Cancer	36
Colon Cancer	37

Rows	Check Status
Weight loss	38
Weight gain	39
Change in energy	40
Hair growth	41
Hair loss	42
Change in urinary function	43
Hot flushes/flashing	44
Breast discharge	45

Select theme:

Rows	Year	Abortion or place of delivery	Duration Pregnancy	Hours of Labor	Type of Delivery	Delivery Complications Mother and/or Infant
Child 1
Child 2
Child 3
Child 4
Child 5

Rows	Sex	Birth Weight	Present Health
Child 1
Child 2
Child 3
Child 4
Child 5

Ob Gyn Patient History Form

Menstrual History

Pregnancy History

History of Birth Control

Sexual History

Past Obstetrical/Gynecological Surgeries

Pap Smear/ Mammogram History

Other Past Gynecological History

Past Medical History

Family History

Other Symptoms