Female Pelvic Exam Intake Questionnaire Form
Use this form to share the details needed before your pelvic exam appointment. Please complete the fields as accurately as possible.
Patient and Visit Details
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Appointment Date and Time
*
Health Intake
Main reason for this visit
*
Current symptoms or concerns
Pain
Unusual bleeding
Discharge
Itching
Pelvic pressure
Other
Date of last menstrual period
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Possibility of pregnancy
*
No
Unsure
Yes
Preferences and Notes
Exam preferences and comfort notes
Special assistance or accessibility needs
Additional notes for the clinician
Submit
Should be Empty: