Ob-Gyn Centre Of Excellence Patient Intake Form Page 2
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4Past Surgical History: Please list all previous surgeries/serious injuries including dates
Hysterectomy: Abdominal Laparoscopic Robotic Vaginal
_______________________________________
_____________________________________________________________________ Date: _______________________
_____________________________________________________________________ Date: _______________________
_____________________________________________________________________ Date: _______________________
_____________________________________________________________________ Date: _______________________
Family History - Please Check All That Apply:
Grand
Grand
Mother
Father
Brother
Sister
Son
Aunt
Uncle
Disease
Daughter
mother
father
Pancreatic Cancer
Breast Cancer
Colon Cancer
Cystic Fibrosis
Depression/Mental Illness
Diabetes
Genetic Disease
Heart Disease
Kidney Cancer
Osteoporosis
Ovarian Cancer
Stroke
Thyroid Disorder
Uterine Cancer
Other Please list below:
Menstrual History:
st
Age of 1
Period: _________
# of Days between Periods ____________
Flow: Light Medium Heavy
# of Days Periods last: ___________
Use: Tampons or Pads
# Used per Day: _________
Date of Last Period: _____________
Certainty of LMP Date: ___________%
Sexually Active: No Yes
Menopause Status: Premenopausal Perimenopausal Postmenopausal
Age Onset: _________
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