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Sabrina O. Falkner
Yolonda M. Smith
Kimberly A. Huynh
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Initial History Questionnaire
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Initial History Questionnaire
Name
*
First
Last
Age
*
Date of Birth
*
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.
*
In the case of a life-threatening emergency, it is our policy to transfuse with blood if it is necessary to save your life.
I understand and agree with the above transfusion policy.
*
I understand that if I am pregnant or needing surgery, I will not be able to keep my appointment if I decline.
Signature
Menstrual History
Age of first menstrual cycle
Are you postmenopausal?
*
Yes
No
If yes, what year did you transition?
*
If your menstrual cycle is regular, your period starts every ___ days
If your menstrual is irregular, your period starts every ___ to ___ days
Duration of bleeding ___ days
Is the flow
Light
Medium
Heavy
Does bleeding or spotting occur between periods?
Yes
No
And/or after intercourse?
Yes
No
Is pain associated with periods?
Yes
No
Do you experience large clots?
Yes
No
First day of last menstrual period
What birth control method(s) do you currently use?
Pregnancy History (All Pregnancies)
Obstetrical history including abortions & ectopic (tubal) pregnancies
Date of Delivery
Duration of Pregnancy
Note Complications Mother and/or Infant
Child's Sex
Child's Birth Weight
Anesthesia
Location of Delivery
Total Number of Pregnancies?
Miscarriages?
Terminations?
PAP SMEAR/MAMMOGRAM/COLONOSCOPY/DEXA History
Date of Last PAP SMEAR
MM slash DD slash YYYY
Have you had an abnormal pap smear?
*
Yes
No
If yes, what year(s)?
*
Have you had treatment for an abnormal pap smear?
*
Yes
No
If yes, what type(s) of treatment have you had?
Colposcopy, year?
Cone Biopsy, year?
Cryotherapy, year?
Loop Excision (LEEP), year?
Date of last mammogram
MM slash DD slash YYYY
Have you had an abnormal mammogram?
*
Yes
No
If yes, what year(s)?
*
What did they diagnose?
Osteoporosis
Osteopenia
Normal Bone Density
Have you had a Colonoscopy?
*
Yes
No
If yes, what year(s)?
*
Was it normal?
*
Yes
No
When is the next colonoscopy due?
1 yr
3 yrs
5 yrs
10 yrs
Other Past Gynecological History
Check any that apply
BREAST MASS
BREAST MASS - BENIGN
BREAST MASS - CANCER
CHLAMYDIA
ENDOMETRIOSIS
FIBROCYSTIC BREAST TISSUE
FIBROIDS
GONORRHEA
HEPATITIS B or C
HERPES-Type 1
HERPES-Type 2
HIV
HPV
INFERTILITY
PCOS
PELVIC INFLAMMATORY DISEASE
PMS/PMDD
POST MENOPAUSAL BLEEDING
SYPHILIS
TRICHOMONIASIS
UTERUS - BICORNUATE
UTERUS - SEPTUM
VAGINAL PROLAPSE
VAGINITIS/BV/YEAST
WARTS (GENITAL)
Other
If Other, Please specify
*
Have you received the Gardasil Vaccine?
Yes
No
Do you desire STD Screening with today's visit?
Yes
No
Past Obstetrical/Gynecological Surgeries
Cesarean section, Year
D&C, Year
Endometrial biopsy, Year
Hysterectomy (Abdominal), Year
Hysterectomy (Vaginal), Year
Hysteroscopy, Year
Infertility Surgery, Year
Laparoscopy, Year
Myomectomy, Year
Left ovarian cyst(s) removed, Year
Right ovarian cyst(s) removed, Year
Left ovary removed, Year
Right ovary removed, Year
Tubal Ligation, Year
Vaginal or bladder repair for prolapse or incontinence, Year
Other Surgeries, Year
Surgery
Year
Past Surgical History (NON-OB/GYN)
*
None
Yes
Please enlist surgery and year
Surgery
Year
Other Past Medical History
Check any that apply
ANXIETY
ARTHRITIS
ASTHMA
BIPOLAR
BLOOD CLOTS (LEG/THIGH/PULMONARY)
BLOOD TRANSFUSION
BREAST CANCER
CANCER
DEPRESSION
DIABETES
DIABETES - DIET CONTROLLED
DIABETES - GESTATIONAL
DIABETES - INSULIN CONTROLLED
DIABETES - Rx CONTROLLED
GERD/ACID REFLUX
HEART CONDITION
HEMATURIA
HEMORRHOIDS
HEPATITIS, LIVER DISEASE
HIGH BLOOD PRESSURE
HIGH CHOLESTEROL
HIV+
KIDNEY DISEASE
MENTAL ILLNESS
MIGRAINES
SKIN CONDITION
THYROID DISEASE
THYROID DISEASE - HYPOTHYROIDISM
THYROID DISEASE - HYPERTHYROIDISM
OTHER
ASTHMA, Year of last known attack?
*
BIPOLAR, Type 1 or Type 2??
*
Please specify Cancer
*
Please specify Heart Condition
*
Please specify Skin Condition
*
Please specify other condition(s)
Current Medications
Name
Dose/Strength
Drug Allergies
*
None
Yes
List Allergies and Reaction
Allergy
Reaction
Current Social History
Alcohol
Light
Heavy
Former
Never
Tobacco
Yes
Former
Never
How many per day?
*
What age did you quit?
*
Recreational Drug Use (Marijuana, etc.)
Yes
Former
Never
Excercise
Yes
Sendentary
Active, but no formal exercise
How many days per week do you excercise?
What is your current occupation/job title?
Relationship Status
Single
Dating
Engaged
Married
Separated
Divorced
Widowed
Same-sex
Family History
Check all that apply
Breast Cancer
Colon Cancer
Diabetes
Hypertension
Ovarian Cancer
Thyroid Disorder
Have you had the BRCA genetic screening?
Yes
No
If yes, what year and result?
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*
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*
Your Phone
*
Requested Appt. Date
*
MM slash DD slash YYYY
