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ASSOCIATED VALLEY OBSTETRICS AND GYNECOLOGY

Talbot Professional Center

4011 Talbot Rd S, Suite 430

Renton, WA 98055

Phone (425) 656-2496 Fax (425) 572-6150

PATIENT ID: ____________ DOCTOR: ________________ NEW OB DOCTOR APPT ON: __________ INTAKE DATE: ___________

PLEASE FILL OUT ALL PAGES COMPLETELY IN ORDER TO AVOID DELAY IN YOUR SCHEDULED APPOINTMENT

NAME

AGE

HT

ETHNIC

RELIGION

OCCUPATION

PATIENT:

FATHER OF BABY:

MARITAL STATUS:

FULL TERM

PREMATURE

TOTAL # PREGNANCIES

MISCARRIAGE

ELECTIVE ABORTION

LIVING CHILDREN

37 WEEKS OR MORE

LESS THAN 37 WEEKS

OFFICE USE ONLY

LMP: ______________________= EDC DATE: _________________

U/S DATE: __________GEST AGE AT U/S: __________= EDC DATE: ____________ WT: ________BP: __________

MENSTRUAL AND PAP HISTORY

LAST MENSTRUAL PERIOD:

WAS THIS A PLANNED PREGNANCY?

PREVIOUS MENSTRUAL PERIOD:

HAVE YOU HAD SPOTTING OR

BLEEDING SINCE PREGNANT?

AGE PERIODS STARTED:

WHEN WAS YOUR LAST PAP TEST?

HOW OFTEN ARE YOUR PERIODS?

DO YOU HAVE HISTORY OF AN

ABNORMAL PAP?

LENGTH OF MENSTRUAL FLOW:

WHEN? HOW WAS YOUR ABNORMAL

PAP TREATED?

LAST FORM OF CONTRACEPTION:

HAVE YOU EVER HAD AN INFECTION OF

YOUR UTERUS, TUBES OR OVARIES?

WHEN DID YOU STOP CONTRACEPTION?

OTHER MENSTRUAL AND PAP HISTORY

NOT LISTED

DID YOU DO A HOME PREGNANCY

TEST? IF SO, WHEN?

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