Gynecological & Obstetric Associates


PATIENT
MEDICAL HISTORY

 
Social History
Marital status   
Sex at birth   
   Current gender   
  
Sex of sex partners (select all that apply)   
Have you completed   
Gynecological History
Number of days of bleeding   
Total     Heavy     Light       
Bleeding between periods   
Pain with periods     
Pain with intercourse     
Other pelvic pain   
Are you sexually active?   
Previous IUD use   
Abnormal pap smears   
Any history of   










Do you have (select F = frequently   R = rarely   N = never)
Night sweats   
  
Hot flashes   
  
Vaginal dryness   
  
Difficulty sleeping   
  
Memory loss   
  
Depression   
  
Loss of sex interest   
  
Anxiety   
  
Urine loss cough/sneeze   
  




Add another?  
Were your pregnancies complicated by
Hemorrhage   
  
Infection   
  
Infection with group B strep   
  
Diabetes   
  
Personal History
Any history of   




















Any history of cancer     
Patient Medications

Add another?  
Allergies

Add another?  
Surgeries

Add another?  
Do you use
Vaccines
Flu shot this year   
  
Rubella (MMR) vaccine   
  
Have you had chickenpox or the vaccine?   
  
Hepatitis   
  
Hepatitis vaccine   
  
Gardasil® or HPV   
  
If you are between 18 and 45 years old
Do you have any cats?     
  
Do you eat raw meat?     
  
Do you or your partner ever use
hot tubs, steam rooms or jacuzzis?   
Are you or partner of
Mediterranean descent?     
  
Are you or partner Jewish?     
  
Are you or partner African-American?   
  
Who in your family had: (M=Mother, F=Father, S=Sibling, G=Grandparent)


















Review of Systems































Do you take vitamins?   
  
Do you perform breast self-exams?   
  
Do you exercise regularly?   
  
Have you ever had a colonoscopy?   
  
Will you accept a blood transfusion to save your life?   
  
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