Gynecologic History
Name
DOB
-
Month
-
Day
Year
Date
Age
Today’s Date
-
Month
-
Day
Year
Date
Allergies
Medications
Name / Dose
Gynecologic History
Age at first period
Date of last period
-
Month
-
Day
Year
Date
Exact
Approx
Unknown
Do your periods come regularly?
Yes
No
Bleeding between periods?
Yes
No
Every (how many)
days.
Lasting for
days.
Flow
Heavy
Mod
Light
Cramps
Mild
Mod
Severe
Sexual History
Are you sexually active?
Yes
No
Men
Women
Both
Lifetime partner count
# of partners in last 6 mo
Pain with intercourse?
Yes
No
Bleeding after intercourse?
Yes
No
History of an STD?
Yes
No
Chlamydia
Gonorrhea
Herpes
Date of diagnosis
-
Month
-
Day
Year
Date
Treated
Yes
No
Trichomonas
Syphilis
Pap History
Date of last pap smear
History of abnormal pap?
Yes
No
Colposcopy (biopsy)
LEEP
Cone
Did you get the HPV vaccine?
Yes
No
Date
-
Month
-
Day
Year
Date
# of shots in you received
1
2
3
Contraception
Abstinence
Calendar/Rhythm
Condoms
Hysterectomy
IUD
Nexplanon
Pill
Ring
Tubal ligation
Vasectomy
Withdrawal
Nothing
Condom Usage?
Always
Usually
No
Health Maintenance
Date of last
Mammogram
Bone density scan
Colonoscopy
Menopause
Age at menopause
Bleeding after menopause?
Yes
No
Hormone replacement therapy?
Yes
No
OB History
Total pregnancies
Full term
Preterm
Abortions
Ectopic
Miscarriage
Multiples birth
Living Children
Rows
Child’s Name/DOB
Gestational age
Weight of baby
Vag/C section
Complications
Preg #1
Preg #2
Preg #3
Preg #4
Preg #5
Preg #6
Social History
Tobacco
Current
Former
Never
Packs per day
How many years?
E-cig/Vape
Current
Former
Never
Cartridge strength
Cartridge freq
Marijuana use?
Yes
No
Smoke
Vape
Edibles
Freq
Illicit drug use?
Yes
No
If yes, what kind?
Currently employed?
Yes
No
Occupation
Education level
Marital status
Single
Married
Divorced
Widowed
Live with others?
Yes
No
# of children in your home
Alcohol intake?
None
Occ
Mod
Heavy
# of drinks / week?
Bev of choice
Caffeine intake?
None
Occ
Mod
Heavy
# of drinks / day?
Bev of choice
Self-breast exam?
Yes
No
If yes, how often?
Seat belts used routinely?
Yes
No
Diet
Regular
Vegetarian
Vegan
Gluten free
Diabetic
Keto
Cardiac
Paleo
Safety
Do you feel safe at home?
Yes
No
Are you afraid of your partner?
Yes
No
Has anyone close to you ever threatened to hurt you?
Yes
No
Has anyone ever forced you to have sex?
Yes
No
List all Surgeries you’ve had:
Medical History
Rows
Yes
No
Abuse/Domestic Violence
Acid Reflux (GERD)
Acne
Anemia
Anesthesia comp.
Anxiety
Auto immune disease
Asthma
Birth defects
Blood clots
Blood transfusion
Breast problem
Depression
Diabetes
Skin disorder
Eating disorder
Fibroids
Gl problems
Heart problem
Hematologic disorder
High cholesterol High
blood pressure
Kidney/Bladder problem
Liver problems
Migraines with Aura
Osteoporosis
Psychiatric illness
Seizures
Stroke
Thyroid problems
Uterine problems
Arthritis
Cancer
Endometriosis
Infertility
Headaches
Family History
Rows
Yes
No
Yes (If yes, details)
Cancer
Heart attack
Stroke
Diabetes
High blood pressure
Thyroid disease
Endometriosis
Substance abuse
Blood Clot
Submit
Should be Empty: