Ob-Gyn Centre Of Excellence Patient Intake Form Page 3
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4Pregnancy History:
# of Pregnancies: _____ # Full Term: _____ # Premature: _____ # Miscarriage: ______ # Abortions: _____ # Ectopics:_____
# of Vaginal Deliveries: _____ # of C-Sections: _____
Total
Date of
Weeks
Hours
Birth
Type of
Method of
Location of
Delivery
Pregnant
Labor
Weight Sex
Delivery
Anesthesia
Early Labor
Complications
Delivery
Details regarding pregnanies you feel the doctor should know:
Social History – Please Circle One:
Marital Status:
Single
Married
Separated
Divorced
Widowed
Use of Alcohol:
Never
Rarely
Moderate
Daily
Use of Tobacco:
Never
Quit
Current packs/day: _________________________________
Use of Drugs:
Never
Type/Frequency: ____________________________________________________
Has anyone close to you ever threatened to hurt you: Yes No
Has anyone ever hit, kicked, choked, or hurt you physically: Yes No
Has anyone, including your partner, ever forced you to have sex: Yes No
Are you ever afraid of your partner: Yes No
Preventative Screening/Immunizations - Please select all that apply and date performed/given:
Cervical Cancer Screening (Pap Smear):_____________
Mammogram: _____________________
Colonoscopy ______________________
Bone Density: _____________________
Do you perform monthly breast exams: Yes No
Flu Vaccination: ___________________
HPV (Gardisail Vaccination) Series 1
Series 2
Series 3
TDap Vaccination __________________
High Risk Assessment Critera - Please check all that apply:
Vaginosis
Genital Warts
Chlamydia
Gonorrhea
Trichomonas
Syphilis
Have you had a Pap smear in the last 7 years: Yes No
Have you ever had an abnomal pap test: Yes No
Did you begin sexual activity before you were 16 years old: Yes No
Have you had more than 5 sexual partners in your lifetime: Yes No
Have you ever tested positive for HIV virus: Yes No
Did your mother take the drug DES when she was pregnant with you: Yes No
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