Patient Information Form Page 3
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3Patient Information Questionnaire
Name:_________________________________________ Phone #:________________ Today’s Date:_______________
DOB:________________________ Age:_____________ Referred by:_______________________________________
Please Provide The Following Information
General Information
What is your primary reason for coming to see us today?
Routine Exam
Other __________________________
How many times have you been pregnant? _______________
Gynecologic and Obstetric Review:
If you have menstrual periods, when did your last menstrual period start? ________________________
If you do not have periods, please answer the following
Have you had a hysterectomy?
Y
N
Have you been through menopause?
Y
N
Have you had your ovaries removed? Y
N Do you take hormone medication?
Y
N
Are you presently sexually active?
Y
N
Have you ever been sexually active?
Y
N
Do you plan a pregnancy in the near future?
Y
N
What are you using to prevent pregnancy?
Nothing Condoms Diaphram Pills Shots Implants IUD
Tubal Ligation Vasectomy Other ______________________________
Do you want to continue your present method?
Y
N
OB/GYN Review of Systems:
Have you ever had gonorrhea, Chlamydia, herpes, genital warts or other sexually transmitted disease?
Y
N
Do you want to be tested for sexually transmitted diseases today?
Y N
Have you ever experienced problems with your breasts or pelvic organs?
Y
N
Have you had any GYN or abdominal surgery?
Y
N
Do you have:
Breast Problems Breast Pain Breast Lumps Nipple Discharge Abdominal Pain Pelvic Pain Genital Pain
Heavy Periods Painful Periods Irregular Periods Leakage of Urine Abnormal Vaginal Discharge Sexual Problems
Infertility Abnormal Body Hair Other Problems ____________________________________________
General Medical Review of Systems:
Did you have any serious illness as a child? Y N
Have you had problems with:
Fevers
Night Sweats
Eyes/Vision
Ears/Nose/Throat Heart
Chest Pain
Blood Pressure
Lungs
Breathing
Stomach
Ulcers
Liver
Gallbladder
Bowels
Kidneys
Bladder
Back/Spine
Blood
Bruising Diabetes
Thyroid
Headaches/Migraines Seizures/Convulsions
Stroke
Blood Clots in Veins or Lungs
Varicose Veins
Skin
Muscle Disorders
Cancer
Mental Illness
Social and Family History:
What is your marital status?
S M D W
Where do you work?_____________________________________
What is your job? ____________________________________
Do you smoke or use tobacco? Y N
If “yes” how many per day?_____________________________
Do you drink alcohol? Y N
If “yes” how many drinks per day?_______________________
Have you ever used street drugs?
Y N
If “yes” when was the last time?_________________________
Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by anyone? Y N
Within the last year, has anyone forced you to have any sexual activities? Y N
Since your Last Visit, has anyone in your family developed:
Colon Cancer
Breast Cancer
Ovarian Cancer
Diabetes
Heart Disease
Tuberculosis
Birth Defects
Bleeding Disorders
Mental Illness
Are you up to date on your immunizations? Y N
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