New Patient Obstetrics & Gynecology Form

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New Patient Obstetrics & Gynecology Form
This will become part of your medical record.
Today’s Date:
Name:
Date of Birth:
Age:
Primary Care Physician:
Telephone:
Pharmacy:
Pharmacy Address:
Menstrual History:
First day of last menstrual period
Age at first menstrual period
years
Number of days from the start of one period to the start of the next
days
Number of days that you bleed
days
Describe the amount of menstrual flow (circle one)
light / moderate / heavy / clots
How many tampons or pads do you use on your heaviest day?
Describe the amount of menstrual discomfort (circle one)
none / mild / moderate / severe
Do you bleed in between your periods?
Yes
No
Do you bleed after intercourse?
Yes
No
If you stopped menstruating, at what age did you stop?
years
Have you had bleeding or spotting since your periods stopped?
Yes
No
Contraceptive and Sexual History:
Present birth control method:
Birth control methods used in the past:
METHOD
LENGTH OF USE
REASON FOR DISCONTINUATION
1)
2)
Have you ever been sexually active (had intercourse)?
Yes
No
Have you had a new sexual partner in the past three months?
Yes
No
How many sexual partners have you had in the past 3 months?
Is/Are your partner(s) male, female, or both?
Male
/
Female
/
Both
Do you experience pain or discomfort with sexual intercourse?
Yes
No
Would you like to discuss sexual activity or birth control today?
Yes
No
Gynecological History:
Have you been vaccinated for Human Papilloma Virus (HPV) – Gardasil
Yes
No
Last Pap Smear
Last Mammogram
Last Bone Density (DEXA)
Last Colonoscopy
Have you ever been on hormone therapy (estrogen / progesterone)?
Yes
No
Any personal history of:
Abnormal Pap Smears
Yes
No
Sexually transmitted diseases
Yes
No
List:
Fibroids
Yes
No
Endometriosis
Yes
No
Infertility
Yes
No
Urinary incontinence
Yes
No

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