Gynecology Intake Form

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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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