Medical Arts Obstetrics and Gynecology

Name

Age

Date of Birth

Today's Date

Reason for visit today

Allergies

List any allergies you have to medications

What is your preferred Pharmacy?

Location (street and city)

Menstrual History

First day of last menstrual period

Date of last pap

Date of last mammogram

Tobacco History

Do you use tobacco?

Yes

Quit

Quit Date

Medications

List all medications you are currently taking

Add a Medication

Gynecologic History

Are your Menses

Regular/Monthly Irregular No Menses

No Menses due to

Cycles occur approximately every how many days?

Average days of flow

Do you have pain with menses?

Yes No

Age of first Menses

Do you use hormone replacement?

Yes No

Duration of hormone use

Have you ever had sexual activity?

Yes No

Your sexual partner(s) are

Male

Female

Are you sexually active currently?

Yes No

Do you have pain with sexual activity?

Yes No

Are you trying to get pregnant?

Yes No

Do you use any method of contraception?

Yes No

Contraception currently using

Contraception previously used

Have you had an abnormal Pap or HPV test results?

Yes No

What Month/Year

Have you ever had a LEEP, cone, or other treatment for an abnormal Pap?

Yes No

When?

Have you received the vaccination for human papillomavirus (Gardasil)?

Yes, all 3 shots Partially Complete No

Have you ever had

Fibroids

Endometriosis

Ovarian Cysts

Infertility

Sexually Transmitted Infection

Genital Herpes

History of Domestic Violence

Sexual Abuse

Pregnancy History

# Pregnancies

# Deliveries

# Miscarriages

# Ectopics

# Stillbirths

# Abortions

List deliveries you have had, and any complications

Add a delivery

Medical History

Type of Cancer

Specify Other

Comments on Medical History

Surgical History

List any surgeries or procedures you have had

Add a surgery or procedure

Family History

List any family members who have had these conditions, and age at diagnosis

Breast Cancer

Family members and age diagnosed

Ovarian Cancer

Family members and age diagnosed

Uterine Cancer

Family members and age diagnosed

Colon Cancer

Family members and age diagnosed

Other Cancer

Specify other and list family members and age diagnosed

Any family history of the following conditions?

Diabetes

Osteoporosis

Blood clots in a deep vein or lung

Hypertension

Birth Defects

Mental Retardation or developmental delay

Social History

Do you drink alcohol?

Yes No

Average number of drinks per week?

Do you use recreational drugs?

Yes No

Have you ever used IV Drugs?

Yes No

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Patient/Guardian Signature

Date

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