GYNECOLOGY INTAKE FORM
DATE: _______/_______/_______
AGE: _____________________
NAME: ______________________________________________________________ BIRTH DATE: _______ /______/_______
ADDRESS:_________________________________________________________________________________________________
CITY
STATE/ZIP
HOME #: _________________________ CELL #: _________________________ WORK #: _____________________________
PRIMARY CARE MD: _______________________________________________
HEIGHT: __________________________
An advance directive is a document that indicates your medical care wishes if you are unable to make
medical decisions (ie. Coma). Would you like to fill out an advanced directive?
No
Yes
Anything you want to talk to your physician about:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
ALLERGIES
MEDICATIONS
DRUG NAMES
DOSAGE
DRUG NAMES
DOSAGE
GYN HISTORY
Menstrual History
What is the first day of your last menstrual period? _____________ How long does it last? ____________
How many days apart are your menstrual cycles starting
from the first day of one cycle to the first day of your next cycle?__________________________________
What age did you start having menses? _____________
When was your last PAP smear? _______________________
Have you ever had an abnormal Pap smear? No
Yes
When? ____________
What abnormality? __________________________________
Have you ever been treated for:
Chlamydia
Gonorrhea
Genital Warts
Herpes
Trichomonas
Syphilis
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