Gynecology Intake Form Page 2
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4Have you ever tested positive for HIV?
No
Yes
Did you mother take the drug DES when she was pregnant with you? No
Yes
Are you currently sexually active?
No
Yes Never
Did you begin sexual activity before 16yo? No
Yes
If yes, Age started: _________
Have you had > 5 sexual partners in your lifetime? No
Yes
If yes, how many? _________
Sexual Orientation _______________________________
Are you currently using birth control?
No
Yes
Trying to get pregnant
Current birth control: __________________________________ Are you satisfied with it: No Yes
Past Birth control methods:
Condoms
Birth control pills
Withdrawal
Tubal Ligation
Diaphragm
Patch
Rhythm
Vasectomy
Vaginal Film
Vaginal Ring
IUD
Essure
PREGNANCY HISTORY
Number
Number
Number
Total times pregnant
Full term deliveries
Cesarean sections
Miscarriages
Deliveries before 37 weeks
Forceps or vacuums
Abortions
Living children
Describe any special pregnancy problems:
PERSONAL MEDICAL HISTORY
MAJOR ILLNESSES
YES
YES
YES
Diabetes
Heart Disease
Anxiety
High Blood Pressure
High cholesterol
Depression
GI Reflux disease
Hepatitis
Seizures
Other GI disease
Liver problem
Asthma
Fibroids
Kidney infections/stones
Lung disease
Endometriosis
Arthritis
Tuberculosis
Osteopenia
Joint Pain
Thyroid disease
Osteoporosis
Fracture
Clotting disorder
Cancer (Type)
Add others/Explain:
SURGICAL HISTORY
SURGERY
YEAR
SURGERY
YEAR
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