New Patient Form (Ob/gyn) Page 2
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2Please complete the form and bring it with you to your appointment. Thank you.
I have the following Ob/Gyn concerns I would like to address today: ___________________________________________
__________________________________________________________________________________________________
List the number:
pregnancies ___
full term birth ___
preterm birth (>3 weeks prior to due date) ___
Miscarriage ___
ectopic ___
termination
living children
Cesarean section:
no
yes, #______ reason: _________________________________________________________
Sexually active:
no
yes; partner(s) are:
male
female
Painful intercourse:
no
yes
Contraception:
no
yes, _________________________________________________________________________
STDs:
no
yes, list: ______________________________________________________________________________
Abnormal pap:
no
yes
Gardasil/HPV vaccine:
no
yes
Bothersome leakage of urine:
no
yes
Menopause:
no
yes, year of last period ____________.
If yes: Any vaginal bleeding since menopause?
no
yes
Any bothersome menopausal symptoms?
no
yes ____________________________
Complete the following if you have not undergone menopause:
Regularly timed menses: no
yes
Number of days from first day of period to first day of next period: _________
Painful periods:
no
yes
Heavy periods: no
yes
Health Maintenance:
Last mammogram (usually start age 40): month/year ____________________
never had
Last colonoscopy (usually start age 50): year ___________. I was told to return ___________.
never had
Last DEXA (usually start age 65): year _____________________
never had
Received shingles vaccine (recommend age 60):
no
yes
Received pneumococcal (pneumonia) vaccine (recommend age 65):
no
yes
Received flu vaccine:
no
I receive annually
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Parent category: Medical