OB/GYN COMPREHENSIVE PATIENT INTAKE HISTORY

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FOR OFFICE USE ONLY NEW PATIENT ESTABLISHED PATIENT CONSULTATION REPORT SENT: / / OB/GYN COMPREHENSIVE PATIENT INTAKE HISTORY PATIENT NAME: AGE: BIRTHDATE / / DATE: / / RACE: CAUCASIAN AFRICAN-AMERICAN OTHER REFERRED BY: PCP: WHY HAVE YOU COME TO THE OFFICE TODAY? IS THIS A NEW PROBLEM? PLEASE DESCRIBE YOUR PROBLEM, INCLUDING WHERE IT IS, HOW SEVERE IT IS AND HOW LONG IT HAS LASTED. If you are uncomfortable answering any questions, leave them blank; you can discuss them with your Provider. LAST NORMAL MENSTRUAL PERIOD (FIRST DAY) / / PROVIDER NOTES AGE PERIODS BEGAN: LENGTH OF PERIODS (NUMBER OF DAYS OF BLEEDING) NUMBER OF DAYS BETWEEN PERIODS: ANY RECENT CHANGES IN PERIOD? ARE YOU CURRENTLY SEXUALLY ACTIVE? HAVE YOU EVER HAD SEX? NUMBER OF SEXUAL PARTNERS (LIFETIME) PRESENT METHOD OF BIRTH CONTROL HAVE YOU EVER USED: YES NO IF YES, HOW LONG? INTRAUTERINE DEVICE (IUD) BIRTH CONTROL PILLS DEPO PROVERA VAGINAL RING PATCH IMPLANON WHEN WAS YOUR LAST PAP TEST? WHAT WAS THE RESULT? HAVE YOUR EVER HAD AN ABNORMAL PAP TEST? Yes No HAVE YOU BEEN EXPOSED TO DIETHYLSTILBESTROL? (DES) Yes No DO YOU DO BREAST SELF-EXAMINATIONS? Yes No WHEN WAS YOUR LAST MAMMOGRAM? (DATE) WHEN WAS YOUR LAST COLORECTAL SCREEN? (DATE) WHEN WAS YOUR LAST BONE DENSITY SCAN? (DATE) Page 1 of 6

OBSTETRIC HISTORY NUMBER NUMBER NUMBER PREGNANCIES ABORTIONS MISCARRIAGES PREMATURE BIRTHS (37 WEEKS) LIVE BIRTHS LIVING CHILDREN ANY PREGNANCY COMPLICATIONS? DIABETES HYPERTENSION/HIGH BLOOD PRESSURE PREECLAMPSIA/TOXEMIA OTHER ANY HISTORY OF DEPRESSION BEFORE OR AFTER PREGNANCY? NO YES, HOW TREATED CURRENT MEDICATIONS (Including hormones, vitamins, herbs, nonprescription medications) DRUG NAME AND DOSAGE WHO PRESCRIBED DRUG NAME AND DOSAGE WHO PRESCRIBED FAMILY HISTORY $ MOTHER LIVING DECEASED-CAUSE AGE: FATHER LIVING DECEASED-CAUSE AGE: SIBLINGS: NUMBER LIVING: NUMBER DECEASED: CAUSE(S)/AGES: CHILDREN: NUMBER LIVING: NUMBER DECEASED: CAUSE(S)/AGES: ILLNESS YES WHICH RELATIVE(S) AND AGE OF ONSET PROVIDER NOTES DIABETES STROKE HEART DISEASE BLOOD CLOTS IN LUNGS OR LEGS HIGH BLOOD PRESSURE HIGH CHOLESTEROL OSTEOPOROSIS (WEAK BONES) HEPATITIS HIV/AIDS TUBERCULOSIS BIRTH DEFECTS ALCOHOL OR DRUG PROBLEMS BREAST CANCER COLON CANCER UTERINE CANCER MENTAL ILLNESS/DEPRESSION ALZHEIMER S DISEASE OTHER Page 2 of 6

SOCIAL HISTORY YES NO PROVIDER NOTES EVER SMOKED? CURRENT SMOKING: PACKS PER DAY: YEARS: ALCOHOL: DRINKS PER DAY: DRINKS PER WEEK: TYPE OF DRINK: DRUG USE SEAT BELT USE REGULAR EXERCISE: HOW LONG AND HOW OFTEN? DAIRY PRODUCT INTAKE AND/OR CALCIUM SUPPLEMENTS: DAILY INTAKE: HEALTH HAZARDS AT HOME OR WORK? HAVE YOU BEEN SEXUALLY ABUSED, THREATENED, OR HURT BY ANYONE? DO YOU HAVE AN ADVANCED DIRECTIVE (LIVING WILL)? ARE YOU AN ORGAN DONOR? PERSONAL PROFILE YOUR CHOICE OF SEXUAL PARTNERS : MEN WOMEN BOTH MARITAL STATUS: MARRIED LIVING WITH PARTNER SINGLE WIDOWED DIVORCED NUMBER OF LIVING CHILDREN: NUMBER OF PEOPLE IN HOUSEHOLD: SCHOOL COMPLETED: HIGH SCHOOL SOME COLLEGE/AA DEGREE COLLEGE GRADUATE DEGREE OTHER CURRENT OR MOST RECENT JOB: TRAVEL OUTSIDE THE UNITED STATES? PERSONAL PAST HISTORY OF ILLNESS MAJOR ILLNESSES YES (DATE) NO NOT SURE PROVIDER NOTES ASTHMA PNEUMONIA/LUNG DISEASE KIDNEY INFECTIONS/STONES TUBERCULOSIS FIBROIDS SEXUALLY TRANSMITTED DISEASE/CHLAMYDIA INFERTILITY HIV/AIDS HEART ATTACK/DISEASE DIABETES HIGH BLOOD PRESSURE STROKE RHEUMATIC FEVER BLOOD CLOTS IN LUNGS OR LEGS EATING DISORDERS AUTOIMMUNE DISEASE (LUPUS) CHICKENPOX CANCER REFLUX/HIATAL HERNIA/ULCERS DEPRESSION/ANXIETY ANEMIA BLOOD TRANSFUSIONS SEIZURES/CONVULSIONS/EPILEPSY BOWEL PROBLEMS GLAUCOMA CATARACTS ARTHRITIS/JOINT PAIN/BACK PROBLEMS BROKEN BONES OSTEOPENIA/OSTEOPOROSIS HEPATITIS/YELLOW JAUNDICE/LIVER DISEASE THYROID DISEASE PAGE 3 OF 6

PERSONAL PAST HISTORY OF ILLNESSES (Continued) MAJOR ILLNESSES YES (DATE) NO NOT SURE PROVIDER NOTES GALLBLADDER DISEASE HEADACHES DES EXPOSURE INFERTILITY BLEEDING DISORDERS OTHER OPERATIONS/HOSPITALIZATIONS REASON DATE HOSPITAL 1. 2. 3. 4. 5. INJURIES/ILLNESS TYPE DATE TYPE DATE 1. 7. 2. 8. 3. 9. 4. 10. 5. 11. 6. 12. IMMUNIZATIONS/TEST DATE TETANUS-DIPHTERIA BOOSTER INFLUENZA VACCINE (FLU SHOT) HEPATITIS A VACCINE HEPATITIS B VACCINE VARICELLA (CHICKENPOX) VACCINE PNEUMOCOCCCAL (PNEUMONIA) VACCINE MEASLES-MUMPS-RUBELLA (MMR) VACCINE TUBERCULOSIS (TB) SKIN TEST: RESULT: GARDASIL: #1 / / #2 / / #3 / / DATE PROVIDER NOTES: Page 4 of 6 Page 4 of 6

1. CONSTITUTIONAL REVIEW OF SYSTEMS Please check (x) if any of the following symptoms apply to you now or since adulthood (Age 18) WEIGHT LOSS WEIGHT GAIN FEVER FATIGUE CHANGE IN HEIGHT 2. EYES DOUBLE VISION SPOTS BEFORE EYES VISION CHANGES GLASSES/CONTACTS 3. EAR, NOSE, AND THROAT EARACHES RINGING IN EARS HEARING PROBLEMS SINUS PROBLEMS SORE THROAT MOUTH SORES DENTAL PROBLEMS 4. CARDIOVASCULAR CHEST PAIN OR PRESSURE DIFFICULTY BREATHING ON EXERTION SWELLING OF LEGS RAPID OR IRREGULAR HEARTBEAT 5. RESPIRATORY PAINFUL BREATHING WHEEZING SPITTING UP BLOOD SHORTNESS OF BREATH CHRONIC COUGH 6. GASTROINTESTINAL FREQUENT DIARRHEA BLOODY STOOL NAUSEA/VOMITING/INDIGESTION CONSTIPATION INVOLUNTARY LOSS OF GAS OR STOOL 7. GENITOURINARY BLOOD IN URINE PAIN WITH URINATION STRONG URGENCY TO URINATE FREQUENT URINATION INCOMPLETE EMPTYING INVOLUNTARY -UNINTENDED URINE LOSS URINE LOSS WHEN COUGHING/LIFTING ABNORMAL BLEEDING NOW PAST NOT SURE PROVIDER NOTES PAINFUL PERIODS Page 5 of 6

REVIEW OF SYSTEMS (Continued) NOW PAST NOT SURE PROVIDER NOTES 7. GENITOURINARY (Continued) PREMENSTRUAL SYNDROME (PMS) PAINFUL INTERCOURSE ABNORMAL VAGINAL DISCHARGE 8. MUSCULOSKELETAL MUSCLE WEAKNESS MUSCLE OR JOINT PAIN OSTEOPOROSIS 9a. SKIN RASH SORES DRY SKIN MOLES (GROWTH OR CHANGES) 9b. BREASTS PAIN IN BREAST NIPPLE DISCHARGE LUMPS 10. NEUROLOGIC DIZZINESS SEIZURES NUMBNESS TROUBLE WALKING MEMORY PROBLEMS FREQUENT HEADACHES 11. PSYCHIATRIC DEPRESSION OR FREQUENT CRYING ANXIETY 12. ENDOCRINE HAIR LOSS HEAT/COLD INTOLERANCE ABNORMAL THIRST HOT FLASHES 13. HEMATOLOGIC/LYMPHATIC FREQUENT BRUISES CUTS DO NOT STOP BLEEDING ENLARGED LYMPH NODES (GLANDS) 14. ALLERGIC/IMMUNOLOGIC MEDICATION ALLERGIES IF ANY, PLEASE LIST ALLERGY AND TYPE OF REACTION LATEX ALLERGY OTHER ALLERGIES PLEASE LIST ALLERGY AND TYPE OF REACTION FORM COMPLETED BY PATIENT OFFICE NURSE PROVIDER OTHER PAGE 6 OF 6 SIGNATURE OF PATIENT: DATE REVIEWED BY PROVIDER WITH PATIENT: / / PROVIDER SIGNATURE: ANNUAL REVIEW OF HISTORY: DATE REVIEWED: / / PROVIDER SIGNATURE: DATE REVIEWED: / / PROVIDER SIGNATURE: DATE REVIEWED: / / PROVIDER SIGNATURE: DATE REVIEWED: / / PROVIDER SIGNATURE: PTCOBGYN 04/12

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