Gynecologic Intake History - PatientPop
Gynecologic Intake History
Name: __________________________ Date:________________
Referred by:_____________________ Birth Date:_____/____/____
Family Physician:_________________ Pharmacy:______________
Review of Systems: Please check if any of the following apply to you now or in the past
Currently Past Notes
Constitutional
Weight Loss
Weight gain
Fever
Fatigue_______________________________________________________________
Eyes
Double vision
Spots before eyes
Vision changes__________________________________________________________
Mouth/Nose
Ear aches
Ringing in ears
Sinus problems
Sore throat
Mouth sores
Dental problems/dentures________________________________________________
Cardiovascular
Painful breathing
Chest pain
Difficult breathing on exertion
Swelling of legs
Palpitations of heart_____________________________________________________
Respiratory
Wheezing
Spitting up blood
Shortness of breath
Chronic cough_________________________________________________________
Gastrointestinal
Frequent diarrhea
Blood in stool
Nausea/vomiting
Constipation___________________________________________________________
Genitourinary
Blood in urine
Pain with urination
Urgency
Frequent urination
Pg 1 of 4
Currently Past Notes
Genitourinary
Stress incontinence
Abnormal periods
Painful intercourse____________________________________________________________
Musculoskeletal
Muscle weakness_____________________________________________________________
Skin/Breast
Pain in breast
Nipple discharge
Breast masses
Skin rash
Skin ulcers___________________________________________________________________
Neurological
Seizures
Dizziness
Numbness
Trouble walking______________________________________________________________
Psychiatric
Depression
Frequent Crying______________________________________________________________
Endocrine
Dry skin
Abnormal thirst
Hot flushes__________________________________________________________________
Blood
Frequent brusing
Cuts that do not stop bleeding
Enlarged lymph nodes__________________________________________________________
Allergies
Allergies
Medication/Drug allergies______________________________________________________
Personal Past History (please circle )
Asthma Cancer
Pneumonia Ulcers
Chronic lung disease Depression/anxiety
Kidney infection/stones Anemia/transfusions
Tuberculosis Seizures/epilepsy
Venereal disease Bowel trouble
Heart attack/murmur/stent Glaucoma
Hypertension Arthritis/joint pain
Diabetes Fracture
Stroke Hepatitis/yellow jaundice
Rheumatic fever Thyroid disease pg 2/4
Operations/hospitalizations
Injuries/Illnesses
Immunizations/Date: Flu shot; Tetnaus: Pneumonia: TB;
Births:
Live births (number) _____ Abortions:______
Miscarriages: ___________ Living children:______ Adopted children:
Medications: Please bring list with you or bring your medications. Include any herbal/vitamin supplements that you take.
Family History (circle if a family member has or had one of these illnesses)
Diabetes Drinking problem
Stroke Breast cancer
Heart disease colon cancer
High blood pressure ovarian cancer
Social History: Personal Habits
Smoking: yes/no Packs per day____ Age when started ____
Alcohol: yes/no Drinks per day_____ Drinks per week ______
Drug use: ____________________
Seat belt use:__________________
Regular exercise: (how much/what do you like to do?)__________________________
Marital status (circle one): Single Married Widowed Divorced
Number of living children: ________
Hobbies:_____________
School completed (circle one): High School College Graduate degree other _____
Current/most recent job:___________________________
Personal Safety
Has anyone close to you ever threatened to hurt you? Yes/no
Has anyone ever hit, kicked, choked, or hurt you physically? Yes/no
Has anyone, including your partner, ever forced you to have sex? Yes/no
Are you ever afraid of you partner? Yes/no pg 3 of 4
Medicare “high risk” criteria: (these questions may change how often Medicare considers you can/should have an annual check up and if they will cover the visit. (please circle if they apply to you.
Vaginosis Genital warts Chlamydia
Trichomonas Gonorrhea Syphilis
Oral/vaginal Herpes
Have you had a Pap smear in the last 7 years? Yes/no
Have you ever had an abnormal Pap smear test? Yes/no If so, when? ______
Did you begin sexual activity before you were 16 years old? Yes/no
Have you had more than 5 sexual partners in you lifetime? Yes/no
Have you ever tested positive for the HIV virus? Yes/no
Did you mother take the dry DES when she was pregnant with you? Yes/no
Signature of patient:______________________________ Date:____________
Date reviewed by physician:_________________________ MD initials:_______
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