OB-GYN Centre of Excellence Patient Intake Form
For Office Use Only
Name: ___________________________________ Today’s Date: ________
BP: ______________ Height: _____________
Date of Birth:______________________________ Age: _______________
Pulse: ___________ Weight: _____________
Temp: ___________ LMP:________________
Primary Care Physician: ________________________________________
(Problems during a wellness exam are subject to an additional charge. This additional charge may result in a
Reason for Visit Today:
copay/coinsurance/deductible payment due. Some insurance companies require a separate visit for problems. You may be asked to return for the problem)
Wellness Exam Wellness Exam with Problems (Please List)_____________________________________________
Other: ___________________________________________________________________________________________
Can we leave test/lab results or appointment information on your voice mail or answering machine? Yes No
Patient History
Allergies: __________________________________________________________________________________________
Pregnancy Prevention: Pills Condoms Depo Provera IUD Nexplanon Surgical Sterilization None
If birth control pills, list medication: _________________________________________________
Patient Medical History – Please check all that apply and list medication to treat condition:
Condition:
Medication(s) with dosage:
Arthrits _____________________________ ____________________________________________________
Asthma _____________________________ ____________________________________________________
Bleeding tendency _____________________ ____________________________________________________
Cancer ______________________________ ____________________________________________________
Diabetes _____________________________ ____________________________________________________
Depression/anxiety/mental illness _________ ____________________________________________________
Heart trouble _________________________ ____________________________________________________
Hepatitis ____________________________ ____________________________________________________
HIV/AIDS ___________________________ ____________________________________________________
High blood pressure ___________________ ____________________________________________________
Hormone replacement therapy ___________ ____________________________________________________
Stroke/deep vein thrombosis _____________ ____________________________________________________
Seizures _____________________________ ____________________________________________________
Sexually transmitted disease _____________ ____________________________________________________
Thyroid disorder ______________________ ____________________________________________________
Other______________________________ _ ____________________________________________________
Other ______________________________ _ ____________________________________________________