Patient Intake Form

Name

DOB

Occupation

Date

Reason for today’s visit - Please select by the appropriate visit:

Well Woman Exam/Annual Visit Prenatal Care IUD/Birth Control Problem Visit/GYN

If you are presenting for a problem visit, please indicate the issue below:

Medications

Drug Allergies

Contraception

Last pap smear

Mammogram

Colon Screen

Bone Density

Last Menstrual Period / Age of Menopause

Regular Menses

Y N

Number of Pregnancies

Assisted Reproduction

Y N

Number of Deliveries (Date and type- vaginal/cesarean)

Pregnancy Complications

History of Herpes

Chlamydia

Gonorrhea

Syphilis

Hepatitis

HIV

HPV

Other Medical Conditions

Past Surgeries and Dates

Family History: Breast, Ovarian, Cervical or Uterine cancer? If so, Whom and What type

Marital Status

Sexually Active

Y N

Tobacco Use

Y N

Alcohol Use

Y N

Drug Use

Y N

If yes what type / how often

Pharmacy name, address, and phone