Urogynecology New Patient Intake Form Page 3
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4How many times have you ever been pregnant?________________
Of these pregnancies, how many were: preterm (premature) deliveries ________________________________________
full term deliveries _________________________________________________
miscarriages or abortions ____________________________________________
Of the deliveries, how many were:
vaginal deliveries only? ______________________________________________
vaginal deliveries with forceps assistance? _______________________________
vaginal deliveries with vacuum assistance? ______________________________
cesarean deliveries? ________________________________________________
Of the vaginal deliveries, did you have any large tears (3rd or 4th degree)? Yes/No
What is the weight of your largest baby? ________________________
When was the first day or your last period? ______________________________________________________________
How often do you have your period? ___________________________________________________________________
How long does your period last? _______________________________________________________________________
Have you ever had an abnormal pap test? _______________________________________________________________
Have you ever had a pelvic infection (i.e. gonorrhea, chlamydia, herpes)? ______________________________________
Do you have a sexual partner? __________________
Is that partner male or female? ________________________
When was your last:
Pap test
_________________
Colonoscopy
__________________
Mammogram
_________________
Bone Density test
__________________
Cholesterol screen
_________________
Tetanus shot
__________________
Are you? Single/Married/Partnered/Divorced/Widowed
Who do you live with? _______________________________________________________________________________
Are you currently? Working/Retired/Unemployed
What is your occupation?_____________________________________________________________________________
Do you exercise regularly? Yes/No
Describe your current exercise routine: _________________________________________________________________
We recommend limiting tobacco use. Do you currently smoke? Yes/No
If yes, how many cigarettes or packs per day? ________________________________________________________
If yes, would you like help quitting smoking? Yes/No
Have you ever smoked in the past? Yes/No
If yes, when did you quit? _________________________________________________________________________
How much alcohol do you use: ____________________________day/week/month
What street drugs do you use? ___________________________
How often? ________________________________
Domestic violence (including emotional physical and sexual abuse) is a serious health threat to women. Has anyone hurt
you in the past? ___________________________________________________________________________________
Is anyone hurting you now in any way? _________________________________________________________________
Wake Specialty Physicians
Women's Center
Patient Label
placed here
Urogynecology New Patient Intake Form
10/13
PAGE 3 OF 4
WSP-214
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