Ob / Gyn Annual Health History Form
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2OB / GYN ANNUAL HEALTH HISTORY
Name:
Age:
Date of last physical exam:
Today's Date:
Phone Number
May we leave messages on your answering machine or cell phone?
YES
NO
Reason for visit
Primary Care Physician
Phone
Physician Address
Medical Conditions:
Surgery/Date
Meds
Allergies
Hospitalizations:
Have you had a hysterectomy? Yes
No
Reason:
Have you had one or both ovaries removed? Yes
No
Reason:
Obstetrical and Gynecological History:
Have you started menopause?
YES
NO
When was your last: Pap exam
__________________
Do you have hot flashes?
YES
NO
Dexa Bone Density Scan
__________________
Do you take any hormone replacements?
YES
NO
Colonoscopy
__________________
If yes, what type?: __________ For how long?: __________
Mammogram
__________________
Have you ever been told that you have osteoporosis?
YES
NO
Have you had any of the following:
Number of times pregnant: ____________
Height loss?
YES
NO
# of living children: _________ # of premature deliveries: __________
Broken hip or wrist?
YES
NO
# of miscarriages: _________ # of abortions: _________
Do you lose urine with moving, coughing, or sneezing?
# of vaginal deliveries: _________ # of cesarean sections: _________
Daily
Weekly
Rarely
Never
Complications? : ____________
Do you lose urine due to urgency to go to the bathroom?
Date of last pregnancy: ____________
Daily
Weekly
Rarely
Never
Have you ever had Gestational Diabetes?: ____________
Do you have reoccurring bladder infections?
YES
NO
Have you ever been treated for urinary incontinence?
YES
NO
Are you sexually active?
YES
NO
First day of last menstrual period (or first & last years of
If no, have you been previously?
YES
NO
menstruation, if through menopause): _______________
Are your partners?
male
female
both
How often are your periods? Every ______ days or months
Do you have pain with intercourse?
YES
NO
How many days do you bleed with each period? ______ days
Have you been treated for sexually transmitted infection?
YES
NO
Do you have:
Heavy bleeding?
YES
NO
If yes, was it?
chlamydia,
gonorrhea
herpes
Pain with periods?
YES
NO
genital warts
syphilis
Bleeding between periods?
YES
NO
Have you been treated for infection in the fallopian tubes
Abnormal vaginal discharge?
YES
NO
(pelvic inflammatory disease)?
YES
NO
Bleeding with intercourse?
YES
NO
What method of birth control do you use?: _______________________
Have you had: any abnormal Pap smears?
YES
NO
Have you used "The Birth Control Pill"?
YES
NO
If yes, dates: _______________Problem: ________________
If yes, for how many years?: _______________________
For abnormality, did you have any of the following done:
Are you having any problem with your birth control?
YES
NO
Re-check pap
YES
NO
_________________________________________________________
Colposcopy
YES
NO
Are you planning a pregnancy in the next 6-12 months?
YES
NO
Cryotherapy
YES
NO
LEEP
YES
NO
People assisting with paperwork:
Interpreter’s name
Interpreter’s Signature and/or ID #
Date and Time
Office Staff name
Office Staff Signature
Date and Time
Patient and Provider need to Date/Time/Initial reviewed annually:
Place patient sticker here or handwrite
Initial review by Provider:
/
/
Date
/ Time
/ Initials
Name: ___________________________
Patient:
/
/
Provider:
/
/
Date
/ Time
/ Initials
Date
/ Time
/ Initials
Cover/AHH
Page 1/2
DOB: ____________________________
Patient:
/
/
Provider:
/
/
Rev 04-2011
Date
/ Time
/ Initials
Date
/ Time
/ Initials
Form 0301
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