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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