New Patient Medical History Form Page 3
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5Do you have bleeding with sexual activity? ▢ Yes
▢ No
Current contraceptive method:
▢ Birth control pill
▢ Injection
▢ IUD
▢ Tubal ligation
▢ Vasectomy
▢ Condoms
▢ Withdrawal
▢ None
▢ Other ____________________
Are you satisfied with your method of contraception? ▢ Yes ▢ No
▢ Yes ▢ No
Any history of sexually transmitted infections?
If yes, please check those that applied:
Herpes
Gonorrhea
Chlamydia
Syphilis
Genital warts
Hepatitis
HIV
Other:
Age at menopause (if applicable):____________________
Are you experiencing hot flashes? ▢ Yes
▢ No
▢ Yes
▢ No
Hormone Replacement Therapy?
Vaginal bleeding after menopause? ▢ Yes
▢ No
▢ Yes
▢ No
Involuntary loss of urine?
Pregnancy History:
# of pregnancies:____________
# of live deliveries:__________
# of miscarriages:____________
# of abortions:_____________
# of ectopic pregnancies:______
# of living children:__________
Date of Birth
Full term/Preterm
Type of delivery
Weight of Baby
(vaginal, forceps, C-
section, etc.)
Baby 1
Baby 2
Baby 3
Baby 4
▢ No
▢ Yes
Any pregnancy complications such as gestational diabetes?
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