Patient Information Template Page 5
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8G
OB/GYN A
, P.C.
WINNETT
SSOCIATES
Gynecology Questionnaire
NAME:
DATE:
DATE OF BIRTH:
REASON FOR VISIT: (If not routine, briefly describe main symptoms.)
PAST MEDICAL HISTORY:
List all operations you have had.
List all illnesses you have had that required hospitalization.
OPERATION
DATE
ILLNESS
DATE
A.
A.
B.
B.
C.
C.
D.
D.
E.
E.
F.
F.
Have you ever had? (Check yes or no and give dates.)
Please list any additional medical conditions or illnesses:
YES
NO
ILLNESS
DATE
YES
NO
ILLNESS
DATE
ILLNESS
DATE
( )
( )
Migraine Headaches
( )
( )
Jaundice of Hepatitis
( )
( )
Thyroid Disorder
( )
( )
Kidney Stones
( )
( )
Pneumonia
( )
( )
Kidney Infection
( )
( )
Tuberculosis
( )
( )
Bladder Infection
( )
( )
Heart Murmur
( )
( )
Genital Herpes
( )
( )
High Blood Pressure
( )
( )
Gonorrhea
( )
( )
Rheumatic Fever
( )
( )
Syphilis
( )
( )
Diabetes
( )
( )
Broken Bones
( )
( )
German Measles or Vaccine
( )
( )
Arthritis
( )
( )
Anemia
( )
( )
Mental Illness
( )
( )
Convulsions or Seizures
( )
( )
Serious Injury
( )
( )
Ulcers
( )
( )
Blood Transfusion
( )
( )
I will accept blood products if necessary
REVIEW OF SYSTEMS:
Are you currently having or have you recently had any of these symptoms? (Check “
” or “
”)
YES
NO
A.
GENERAL
B.
CHEST AND HEART
C.
BREASTS
YES
NO
YES
NO
YES
NO
( )
( )
Recent weight gain
( )
( )
Palpitation
( )
( )
Breast lump
( )
( )
Recent weight loss
( )
( )
Skipped or irregular heart beats
( )
( )
Breast tenderness
( )
( )
Depression
( )
( )
Chest discomfort on exertion
( )
( )
Nipple discharge
( )
( )
Headaches
( )
( )
Chest pain with breathing
( )
( )
Family history of breast cancer
( )
( )
Eye pain
( )
( )
Shortness of breath with exertion
( )
( )
Previous mammogram date _____________
( )
( )
Spots in front of eyes
( )
( )
Awakening at night short of breath
( )
( )
Double vision
( )
( )
Shortness of breath lying down
( )
( )
Glasses
( )
( )
Coughing up blood
( )
( )
Deafness
( )
( )
Nose bleeds
D.
GASTROINTESTINAL
E.
GENITO-URINARY
F.
EXTREMITIES
YES
NO
YES
NO
YES
NO
( )
( )
Change in bowel habits
( )
( )
Frequent or painful urination
( )
( )
Varicose veins
( )
( )
Constipation
( )
( )
Difficulty holding urine
( )
( )
Pain in legs when walking
( )
( )
Diarrhea
( )
( )
Difficulty starting urine
( )
( )
Blood clots in legs
( )
( )
Bright blood in stools
( )
( )
Excessive urine
( )
( )
Skin rashes
( )
( )
Clay colored stools
( )
( )
Frequent night urination
( )
( )
New or growing moles
( )
( )
Black stools
( )
( )
Change of color of urine
( )
( )
Abdominal pain
( )
( )
Blood or pus in urine
( )
( )
Hemorrhoids
( )
( )
Wetting in bed
( )
( )
Vomiting up blood
( )
( )
Painful bowel movements
( )
( )
Nausea or vomiting
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