Patient Medical History Gynecological Form printable pdf download

GREENBRIER OBSTETRICS AND GYNECOLOGY, P.C.

Gynecological Form

Name:____________________________________________________________ DOB:_____________ Age:__________

Race:_____________________

Marital status: Never Married / Married / Divorced /Legally Separated / Widowed

Allergies:_____________________________________________ Latex Allergy:

YES / NO

Iodine Allergy:

YES / NO

Medications:_______________________________________________________________________________________

Main reason for your visit:___________________________________ Other concerns:___________________________

*Do you wish to have Gonorrhea/Chlamydia testing?

YES / NO

*Do you wish to have HIV, Syphilis, and Hepatitis testing?

(blood draw)

YES / NO

*Do you wish to discuss birth control today?

YES / NO

Type:_____________________________________________

PAST MEDICAL HISTORY

Last Pap Smear:_____________________

Result:__________

Have you ever had an abnormal pap smear?

YES / NO

If so, when?________________________

Treatment received:___________________________________________

Last mammogram:__________________

Result:____________

Performed at:______________________________

Last bone density:___________________

Result:____________

Have you ever been diagnosed with (Please circle):

Chlamydia

Genital Herpes

Ectopic Pregnancy

Kidney Problems

Diabetes

Gonorrhea

Genital Warts

Breast Cancer

Bladder Problems

Anemia

PID

HPV

Uterine Cancer

Migraine

Ovarian Cyst

HIV

Uterine Fibroids

Ovarian Cancer

Depression/Anxiety

Asthma

Trichomonas

PCOS

Heart Disease

Bipolar Disorder

Tuberculosis

Hepatitis B

Endometriosis

High Blood Pressure

Osteoporosis

Sickle Cell Trait

Hepatitis C

Uterine Abnormalities

Blood clot in lung/leg

Liver disease

Sickle Cell Disease

Syphilis

Abnormal bleeding

Cystitis

Thyroid disease

Lupus

Other on-going medical conditions not listed:__________________________________________________________

MENSTRUAL HISTORY

First day of last menstrual period (LMP):___________ x ______ days

Number of days between cycles:__________

Flow amount:

Light

/ Moderate / Heavy

Age at first menstrual period:__________________________________

Current birth control method:_______________

Have you had a tubal ligation?

YES / NO

If so, date:__________

Types of other birth control used in the past:

Pills

Depo Provera

Patch

Ring

IUD

Condoms

Vasectomy

PREGNANCY HISTORY

Total number of pregnancies:________

# of live births:_______

# of losses:_______

# of terminations:_______

# of Vaginal:______ Dates:__________________________

# of C-section:______ Dates:_________________________

SURGICAL HISTORY

Have you ever had any problems with anesthesia?

YES / NO

____________________________________________

C-Section

Laser surgery

Removal of ovaries

Breast Augmentation

Appendectomy

Colposcopy

D&C

Removal of ovarian cyst

Breast Reduction

Bladder surgery

Cervical biopsy

Hysteroscopy

Uterine ablation

Breast biopsy

Tonsillectomy

LEEP

Laparoscopy

Fibroid embolization

Lumpectomy

Wisdom tooth

Cone biopsy

Hysterectomy

Myomectomy

Mastectomy

Hernia repair

Cryosurgery

Removal of tubes

Tubal ligation

Removal of Gallbladder

Gastric bypass

Other surgeries:____________________________________________________________________________________

Patient Medical History Gynecological Form

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