Gynecologic History Questionnaire English – Blessings OBGYN

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GYNECOLOGIC HISTORY QUESTIONNAIRE

Name *

Date of Birth *

Date *

Chief reason for today’s visit: *

First day of last menstrual period *

Date of last pap smear

Results: *

Type of birth control currently using *

(Including vasectomy, tubal ligation, condoms, abstinence, or natural family planning methods)

Are you happy with this type of birth control? *

OBSTETRICAL HISTORY

Are you currently pregnant: *

Yes
No

If so, on what date what the first positive pregnancy test:

Total number of times pregnant: *

(including miscarriages and abortions)

Total number of live births : *

(include dates and types of deliveries)

Total number of miscarriages: *

Total number of abortions: *

Any complications during pregnancies? If so, please explain:

Did you have a Cesarean Section: If so, when:

Any family history of inherited disorders:

(i.e. Tay-Sachs, Spina Bifida, Down Syndrome, other genetic disorder)

GYNECOLOGICAL HISTORY

Age at first period: *

how many days do your periods last: *

How often do your periods come: *

Every 28-30 days
More frequently
Less frequently

How heavy is your menstrual flow: *

Light
Moderate
Heavy
Extremely heavy

Do you have bad cramps: *

Yes
No

do you have PMS symptoms: *

Yes
No

Any bleeding between periods: *

Yes
No

any bleeding after intercourse: *

Yes
No

Any problems with urination: *

Yes
No

(loss of urine when coughing, sneezing, etc.)

Check any of the following that you have had either in the past or currently:

Gonorrhea
Pelvic Inflammatory Disease (PID)
Herpes
Vaginal Infections
History of physical or sexual abuse
IUD Related Problems
Abnormal Pap Smears

(what abnormality and when):

MEDICAL HISTORY

How is your overall health: *

Excellent
Good
Fair
Poor

Do you smoke: *

Yes
No

If yes, how much packs per day:

how many years have you smoked:

Are you a past smoker: *

Yes
No

when did you quit:

Do you drink alcohol: *

Yes
No

How many alcoholic beverages do you have in a week?

Social drug use? *

Yes
No

If so, what type of drugs do you use:

Have you ever been diagnosed with a MEDICAL or PSYCHOLOGICAL condition: If so, what was the diagnosis and when:

Have you ever been hospitalized for a medical illness? If so please explain:

What surgeries have you had? (Please provide the year including cosmetic)

Do you have allergies to any medications:

Yes
No

Please list:

Do you have any other allergies:

Yes
No

Please list:

Do you have any history of a bleeding disorder:

Yes
No

had a blood transfusion:

Yes
No

Do you use medication on a regular basis? Please list the name and dosages:

Have you had a mammogram:

Yes
No

Date and result of last mammogram:

Do you have any problems with your breasts: (lumps, discharge, or pain)

FAMILY HISTORY

(Please check if anyone in your family has had any of these conditions and their relationship to you)

Breast Cancer
Uterine Cancer
Ovarian Cancer
Colon Cancer
Diabetes
Heart Disease
High Blood Pressure
Stroke
Osteoporosis
Thyroid Disease
Autoimmune Disease
Other

SOCIAL HISTORY

Marital Status *

Occupation *

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To provide comprehensive healthcare for women in Arizona using today’s modern technologies along with clinically proven techniques in a caring, nurturing and safe environment.

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