Patient History Form Page 2
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4Gynecologic
Oncology
NAME: ________________________________________________________
OBSTETRICAL HISTORY (continued):
Are your periods usually painful? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o Yes
o No
Do you have bleeding or spotting between periods or following intercourse? . . . . . . . . . . . . . . . . . . o Yes
o No
Do you have any abdominal/pelvic pain unrelated to menstruation? . . . . . . . . . . . . . . . . . . . . . . . . . o Yes
o No
Do you ever have any pain with sexual intercourse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o Yes
o No
Do you have any vaginal irritation, discharge, or dryness? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o Yes
o No
Do you have any itching, irritation, sores or lumps around your vulva or vagina? . . . . . . . . . . . . . . . o Yes
o No
Do you have any loss of urine with sneezing/coughing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o Yes
o No
Do you frequently have a sudden urgent need to urinate? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o Yes
o No
Do you have night urination, dribbling of urine or bed wetting? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o Yes
o No
Do you ever have a protrusion or bulging sensation from your vagina? . . . . . . . . . . . . . . . . . . . . . . . o Yes
o No
Have you had a pap smear done in the past 2 years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o Yes
o No
Have you ever had an abnormal pap smear? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o Yes
o No
CURRENT CONTRACEPTION:
o Birth Control Pills
o Diaphragm
o IUD
o Condom
o Tubal
o None
Other: ____________________________________________________________________________________
Are you still currently sexually active?
o Yes
o No
SURGERY: Have you ever had an operation on any of the following?
YEAR
YEAR
YEAR
Gallbladder
____________
Heart
____________
Cervix
____________
Appendix
____________
Tumor
____________
Ovary
____________
Kidney
____________
Hernia
____________
Uterus
____________
Tonsils
____________
Hemorrhoids ____________
Vagina
____________
Thyroid
____________
Chest/Lung
____________
C-section
____________
Breast
____________
Spine
____________
D&C
____________
Bowel
____________
Vulva
____________
Tubal Ligation ____________
1. Others: (example – eyes, head, extremities) ____________________________________________________
_______________________________________________________________________________________
2. Please explain the operation if necessary: _____________________________________________________
_______________________________________________________________________________________
3. Have you ever been advised to have any surgical procedure which has not been done? _________________
If yes, please explain: _____________________________________________________________________
INFECTIOUS DISEASE: Check any of the following that you have had:
o Abscess: describe – _________________________________
o Pneumonia
o Rheumatic Fever
o Bladder / Kidney infection
o Tuberculosis
o Venereal disease
o Herpes: last outbreak – _______________________________
o Tubal infection
o Hepatitis
PAGE 2 OF 4
NGPG FORM # 02422 (5/14/13)
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