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Women's Group of Gwinnett
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      • Sabrina O. Falkner
      • Kimberly A. Huynh
      • Melissa O. Iyoyo
      • Sashana S. Gordon
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Initial History Questionnaire

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  • MM slash DD slash YYYY
  • Acceptance of Blood Products

  • In the case of a life-threatening emergency, it is our policy to transfuse with blood if it is necessary to save your life.
  • Menstrual History

  • Pregnancy History (All Pregnancies)

  • Date of DeliveryDuration of PregnancyNote Complications Mother and/or InfantChild's SexChild's Birth WeightAnesthesiaLocation of Delivery 
  • PAP SMEAR/MAMMOGRAM/COLONOSCOPY/DEXA History

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Other Past Gynecological History

  • Past Obstetrical/Gynecological Surgeries

  • SurgeryYear 
  • SurgeryYear 
  • Other Past Medical History

  • NameDose/Strength 
  • AllergyReaction 
  • Current Social History

  • Family History

Lawrenceville

  • 500 Medical Center Blvd.
    Suite 250, Lawrenceville,
    Georgia 30046

  • 770.979.4700

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