Gynecological & Obstetric Associates


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   
Loss of sex interest   
Urine loss cough/sneeze   

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

Any history of cancer     
Patient Medications

Add another?  

Add another?  

Add another?  
Do you use
Flu shot this year   
Rubella (MMR) vaccine   
Have you had chickenpox or the vaccine?   
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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