Emory Healthcare Initial History Form Page 5
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5Gynecologic History
st
Age when 1
period occurred: ___________ Age at menopause: _______________
No. of pregnancies: ____ No. of children: ____ No. of miscarriages: ____ No. of abortions: ____
Interval between periods (days): ____
Duration of periods (days): ____
Are/were your periods regular? Yes No
Date of last period ____/____/________
Last PAP smear (MM/YY) ____/______
Date of last mammogram ____/________
Result: ___________________________
Result: ____________________________
STD history:
None
Have you had any of the following? If so when were you treated?
Syphilis
Herpes simplex
Gonorrhea
PID
Chlamydia
Genital warts
Is there anything else we need to know?
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