New Patient Intake Form
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1
2Weill Cornell Medical College
Name:____________________________
Department of Obstetrics and Gynecology
MRN:____________________________
Division of Maternal Fetal Medicine
Date of visit: ______________________
New Patient Intake Form
Answer all questions as they apply to you. This form will be added to your medical record.
Please select your physician.
Dr. Gelber
Dr. Grunebaum
Dr. Kalish
Dr. Landres
o
o
o
o
Dr. Lee
Dr. Pri-Paz
Dr. Sharma
Dr. Wasden
o
o
o
o
Who referred you?____________________________________
Primary Care Provider:_______________________________
Age:__________________
Reason for visit: ____________________________________
Menstrual History
st
Date of last menstrual period:_______________ Age(yrs) at 1
period:_________________ Age at Menopause:_________________
My period usually occurs every _______________ days and lasts for _______________days.
Please circle No or Yes.
Heavy Periods: No Yes Painful Periods: No Yes Irregular Bleeding: No Yes PMS (bloating, moody): No Yes
Genetic History
Ethnic Background: ______________________________Partner’s Age & Ethnic Background:_______________________________
Has anyone in your family or your partner’s family had any of the following? If so, please include which family member(s).
Autism_____________________________________________
Mental Retardation__________________________________
Birth Defect ________________________________________
Muscular Dystrophy _________________________________
Congenital Heart Disease______________________________
Open Spine (Bifida)__________________________________
Cystic Fibrosis ______________________________________
Sickle Cell Anemia__________________________________
Down’s syndrome____________________________________
Thalessemia________________________________________
Hemophilia_________________________________________
Unexplained Fetal Loss_______________________________
Huntington’s disease__________________________________
Other_____________________________________________
Gynecologic History
Last Pap smear: _______________ Abnormal Pap Smears: No___Yes___(Year & Treatment given) _________________________
Last Mammogram: ____________ Abnormal Mammograms: No___Yes___(Year & Treatment given)_______________________
Have you ever had any of the following infections? (Please check all that apply).
Gonorrhea _____ Chlamydia_____ Herpes_____ Trichomonas_____ Genital Warts/HPV_____ Syphilis_____ None_____
If so, when and how was it treated?_____________________________________________________________________________
Have you had any of the following conditions? (Please check all that apply).
Uterine Fibroids_____ Infertility_____ Ovarian Cysts_____ Breast disease/biopsy_____ Endometriosis_____ None_____
If so, please detail year and how it was treated?___________________________________________________________________
Contraception/Pregnancy History
Sexually active: No Yes
Medical issues pertaining to sexual activity:___________________
Current method of preventing pregnancy:_____________________________________________
Total number of: pregnancies _____Vaginal deliveries _____ C-Section _____ Miscarriages _____Abortions _____ Ectopic _____
Pregnancy Complications: _____________________________________________________________________________________
Would you accept a blood transfusion in a life threatening situation? NO ___ YES___
Pregnancy History
Date
Delivery Type
Birth Weight
Gender/Name
Complication
*** ALLERGIES: No ___ Yes ___ Please list allergies: ____________________________________________________________
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