Gynecology Intake Form Page 4
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1
2
3
4Yes
No
Has anyone, including you partner, every forced you to have sex?
Yes
No
Are you ever afraid of your partner?
REVIEW OF SYSTEMS
1. CONSTITUTIONAL
NOTES
7. GENITOURINARY
NOTES
Fever
Abnormal Bleeding
Chills
Vaginal discharge/ odor
Fatigue
Vaginal itching/ burning
Weight Loss
Pelvic pain
Weight gain
Menstrual cramps
2. EYES
Painful intercourse
Changes in vision
Genital lump
Double vision
Fertility concerns
3. ENT/ MOUTH
Menopausal concerns
Ear aches
8. MUSCULOSKELETAL
Ringing in the ears
Muscle weakness
Sinus problems
Joint stiffness
Sore throat
Joint pain
Mouth sores
Joint swelling
Dry Mouth
9. SKIN/ BREAST
4. CARDIOVASCULAR
Breast pain
Chest pain
Nipple discharge
Difficulty breathing on
Breast lumps
exertion
Swelling of legs
Rash
Palpitations
Ulcers
Heart Murmurs
11. PSYCHIATRIC
5. RESPIRATORY
Depression
Wheezing
Mood swings
Spitting up blood
Anxiety
Shortness of breath
Suicidal thoughts
Cough
Homicidal thoughts
6. GASTROINTESTINAL
12. ENDOCRINE
Diarrhea
Abnormal thirst
Constipation
Hot flashes
Nausea/vomiting
Tremors
Bloody stool
Cold/ heat intolerance
Abdominal pain
13. HEMATOLOGIC
Indigestion
Frequent bruising
Bloating
Cuts do not stop bleeding
Liver problem/Hepatitis
Enlarged lymph nodes
7. GENITOURINARY
Blood in urine
Pain with urination
Urgency
Urinary Frequency
Urinary Incontinence
11/07 KC
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