Patient Information Template Page 7

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G
OB/GYN A
, P.C.
WINNETT
SSOCIATES
Gynecology Questionnaire (Sheet 2)
NAME:
MEDICATIONS: (List
ALL medications that you take regularly or have taken recently, include all non-prescription drugs.)
1.
3.
2.
4.
ALLERGIES:
Are you allergic to any medications, drugs, chemicals or food? (If YES, list which ones)
CONTRACEPTIVE HISTORY:
(List present and previous history of birth control you have used.)
METHOD TYPE
DURATION OF USE
COMPLICATIONS
PRESENT
PREVIOUS
OBSTETRIC HISTORY:
(List all pregnancies, dates, and outcomes.)
DATE
DURATION
SEX
WEIGHT
COMPLICATIONS
1.
2.
3.
4.
5.
6.
FAMILY HISTORY:
(List family members (father, mother, sister, brother) with any current health problems and their ages. Also list deceased family
members, the cause of death and their ages at death.)
Have any other blood relatives had serious medical problems or inherited problems? Any children born in the family with an abnormality?
SOCIAL HISTORY:
Do you smoke cigarettes?
r Yes No r
How many/day? ____________________________
How many years?
Do you drink alcohol?
r Yes No r
How many drinks/day? _______________________
Per week?
Do you get any regular exercise? r Yes No r
How often? ________________________________
GYNECOLOGIC HISTORY:
M
H
ENSTRUAL
ISTORY
First day of last period: ____________
Age first started period: ______ Usual number of days from one period to the next:
Usual # of days of flow: ___________
Are your periods: Light r Moderate r Heavy Any excessive bleeding or spotting between cycles? r Yes No r
Cramps with periods? r Yes No r
Depression, anxiety, emotional upset before periods? r Yes No r
P
S
:
AP
MEARS
Last pelvic exam: ________________________
Last pap smear: _______________________
Have you ever had an abnormal pap? r Yes No r
If yes, what treatment was done? ________________________________________________ Have your paps been normal since treatment? r Yes No r
Did your mother take hormones while pregnant with you? r Yes No r
V
:
AGINITIS
Yeast: _____________________
Trichomonas: _______________________
Non-specific/Bacterial Vaginitis:
Are you having any problem with discharge now? r Yes No r
S
H
:
EXUAL
ISTORY
Any problems with pain? r Yes No r
Any problem with Orgasm? r Yes No r
Other? _____________
Any history of STDs? HPV r Yes No r
Herpes r Yes No r
Syphilis r Yes No r
Hepatitis r Yes No
HIV r Yes No r
Gonorrhea r Yes No
Chlamydia r Yes No r
Other? _____________
List any Gynecologic surgeries, dates and reasons for surgery:

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