Patient History Form

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Gynecologic
Oncology
NAME: ________________________________________________________
AGE: _________
DATE: ____________
In order to give you the best medical care, it is necessary to be thorough and complete. Your entire medical history
and present complaint will be reviewed with you. You will also have a complete physical examination and whatever
tests and x-rays may be indicated. We would like for you to fill out the following questionnaire completely and
accurately. You will have an opportunity to discuss in detail any part of this history and any medical problems that
you may have. You will also be able to ask any questions that may be troubling you.
THIS IS PART OF YOUR MEDICAL RECORD AND IS KEPT ABSOLUTELY CONFIDENTIAL.
Please check each question that applies to you. Put (?) if uncertain.
MAIN REASON FOR VISIT: ___________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Height: _____________________
Weight: _____________________
Avg. Weight: ___________________
OBSTETRICAL HISTORY:
How many pregnancies have you had? ______ Number of live births by vagina? _____ by C-section? _______
Number of tubal pregnancies: ______
Miscarriages? ______
Abortions? ______
GYNECOLOGICAL HISTORY:
Menstrual History:
Age of first period: ______
Date of last menstrual period: __________________
If not menstruating, stopped at age: ______
Due to menopause?
o Yes
o No
Due to hysterectomy?
o Yes
o No
Reason for hysterectomy: _______________________________
Have you had any bleeding or spotting?
o Yes
o No
Have you missed any periods without being pregnant?
o Yes
o No
Are your periods:
o Regular
o Somewhat irregular
o Very irregular
The interval between first day of one period to first day of next period ranges from ______ to ______ days.
Menstrual flow usually lasts for a total of ______ days.
Menstrual flow usually is:
o Scant
o Moderate
o Heavy
o Excessive with clots
Date of last pap smear: __________________
PAGE 1 OF 4
NGPG FORM # 02422 (5/14/13)

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