New Patient Intake Form |
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Patient name: |
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Reason for today’s visit: |
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Pregnancy History |
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How many pregnancies have you had? |
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Please share the results of each: |
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Full Term |
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Premature |
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Other (ectopic, tubal, molar) |
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Abortion |
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Miscarriage |
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Living Children |
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Any complications during pregnancy, labor, delivery or post-partum period? |
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o 4° Episiotomy o C-section o Post-partum bleeding o Depression o Vaginal lacerations o Forceps |
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o Other: |
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Gynecological History |
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First day of your last menstrual period: |
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How old were you when your menses started? |
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Are you still having menstrual periods? |
o Yes o No |
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If so, periods are: |
o Light o Moderate o Heavy o Bleed through protection |
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How many days between your periods? |
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How many days of menstrual flow? |
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Do you have any pain with your periods? |
o Yes o No |
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Are periods regular? |
o Yes o No |
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Do you pass any clots in menstrual flow? |
o Yes o No |
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Do you have more than 35 days in-between periods? |
o Yes o No |
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Do you get less than 6 periods year? |
o Yes o No |
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Do you have bleeding in-between periods? |
o Yes o No |
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Do you have bleeding after intercourse? |
o Yes o No |
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Do you have a history of anemia? |
o Yes o No |
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Have you ever had a blood transfusion? |
o Yes o No |
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Have you ever been diagnosed with fibroids? |
o Yes o No |
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Have you ever been diagnosed with polyps inside the uterus? |
o Yes o No |
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Are you suffering from pre-menstrual syndrome (PMS)? |
o Yes o No |
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Do you have a history of endometriosis? |
o Yes o No |
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Do you have a history of pelvic pain? |
o Yes o No |
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Are you sexually active now? |
o Yes o No |
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With o one partner, if so, o Male o Female With o multiple partners, if so o Male o Female o Both |
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Do you have any questions about sex you would like to ask? |
o Yes o No |
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Are you satisfied with your current sexual function? |
o Yes o No |
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If you answered “no”, how long have you been dissatisfied with your sexual function? |
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Which of the following problems apply: |
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Little or no interest in sex |
o Yes o No |
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Decreased genital sensation |
o Yes o No |
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Decreased vaginal lubrication |
o Yes o No |
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Problem reaching an orgasm |
o Yes o No |
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Problem with pain during sex |
o Yes o No |
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Other: |
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Would you like to talk about it with your doctor? |
o Yes o No |
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Birth control – If using, please indicate if you are presently experiencing side-effects or if you have in the past: |
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If needed, what is your present method of birth control: |
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Past method(s) of birth control (select all that apply): |
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o Nothing o Pill o Patch o Nuvaring o Rhythm o Implant o Condom o Tubal Ligation o Vasectomy |
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o Hysterectomy o Mirena IUD (progesterone-containing, 5 years) o Copper T IUD (hormone-free, 10 years) |
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o Depo-Provera Injections every 3 months o Essure Hysteroscopic Sterilization o Other: __________________ |
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Future childbearing plans: o I do not desire children in the future o I desire children in the future |
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o I would like to ask a question about this o Other: |
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Date of last Pap Smear: __________________________ Result: |
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Abnormal Pap Smears – Have you ever had an abnormal Pap or Colposcopy? |
o Yes o No |
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Have you had any treatments to your cervix? |
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o No o Cryosurgery o Laser Surgery o LEEP o Conization o Other ______________________ |
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Have you ever had a sexually transmitted disease? |
o Yes o No |
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o Chlamydia o Gonorrhea o Herpes o Syphilis o HIV o Trichomonas |
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Would you like to be tested for a sexually transmitted disease today? |
o Yes o No |
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Do you have frequent yeast infections? |
o Yes o No |
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Do you have recurrent vaginal infections? |
o Yes o No |
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Menopause (if applicable) – Age of menopause (last menstrual period)? |
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Are you currently experiencing: |
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o Hot Flashes o Vaginal Dryness o Sleep Interruptions o Abnormal/Irregular Periods |
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oPost-Menopausal Bleeding o Other: __________________________ |
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Do you experience any of the following: |
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Loss of urine when coughing, sneezing or laughing? |
o Yes o No |
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Frequent urination? |
o Yes o No |
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Pain during urination? |
o Yes o No |
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Need to urinate with little warning? |
o Yes o No |
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Do you ever lose urine before reaching the toilet? |
o Yes o No |
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Difficulty passing urine? |
o Yes o No |
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Frequent bladder infections? |
o Yes o No |
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Frequency of nighttime urination: |
o 0-1 o 2 or more |
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Frequency of daytime urination: |
o 8 or less o 9 – 15 o 16+ |
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Do you still feel full after urination? |
o Yes o No |
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Do you feel pain, pressure, “ball” in the vagina? |
o Yes o No |
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Do you feel like your bladder or uterus are low/dropped? |
o Yes o No |
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Have you ever experienced pelvic organ prolapse? |
o Yes o No |
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Do you have a history of ovarian, cervical or uterine cancer? |
o Yes o No |
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Past Operations/Hospitalizations Please indicate the year and reason for operation/hospitalization |
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Medical History |
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Please list your medical problems (for example, high blood pressure, diabetes, etc): |
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Allergies to Medications (please list medication and what type of reaction you had): |
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Current
Medications: |
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Medication Name (Brand/Generic) |
Dose |
Frequency |
Start Date |
End Date |
Prescribed By |
Initials of Reviewer |
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Social History |
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Current and Past Alcohol Intake (drinks per week): |
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Do you have a problem with recreational drugs ? |
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Have you ever received treatment for substance abuse? |
o Yes o No |
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If you smoke: number of Cigarettes Per Day: |
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Past Cigarette Use (years): |
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Exercise (type, frequency, duration): |
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Describe your diet: |
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Are you losing weight? |
o Yes o No |
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What do you do for work? __________________________________________________ Personal Safety |
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Do you feel safe at home? |
o Yes o No |
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Has anyone, including your partner, ever forced you to have sex? |
o Yes o No |
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Have you ever been sexually, physically or emotionally abused? |
o Yes o No |
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Health Maintenance and Screening: If you’ve had and know the results |
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Date and result of last mammogram: |
Date: ________________ Result: ______________ |
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Have you ever had an abnormal mammogram, breast ultrasound or breast biopsy? |
o Yes o No |
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Do you do self breast exams? |
o Yes o No |
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Date and result of last colonoscopy or sigmoidoscopy (50 +): |
Date: ________________ Result: ______________ |
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Date and result of last thyroid function test: |
Date: ________________ Result: ______________ |
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Date and result of last cholesterol test: |
Date: ________________ Result: ______________ |
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Date and result of last diabetes test: |
Date: ________________ Result: ______________ |
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Date and result of last bone density test: |
Date: ________________ Result: ______________ |
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Date and result of last HIV test: |
Date: ________________ Result: ______________ |
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Date of last HPV vaccine: |
Date: ________________ Result: ______________ |
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If you had, did you receive all three shots? |
o Yes o No |
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Date of last tetanus immunization: |
Date: ________________ Result: ______________ |
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Do you have another primary care provider (family doctor, internist, nurse practitioner) who is taking care of you for regular check-ups? |
o Yes o No |
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If yes, please provide name, address and phone number: ______________________________ |
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Family History Parents, Grandparents, Siblings, Children – Please indicate the person(s) |
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o Breast Cancer |
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o Ovarian Cancer |
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o Uterine Cancer |
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o Colon Cancer |
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o Diabetes |
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o High Cholesterol |
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o High Blood Pressure |
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o Heart Disease |
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o Osteoporosis |
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o Premature Menopause |
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o Alzheimer’s Disease |
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o Other: ___________________________________ |
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Review of Systems : Are you experiencing any of the following? |
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1. Constitutional |
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Fatigue |
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o Yes o No |
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Fever |
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o Yes o No |
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Unintentional Weight Loss |
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o Yes o No |
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Unintentional Weight Gain |
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o Yes o No |
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2. Ears/Nose/Mouth/Throat |
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Frequent Nosebleeds |
o Yes o No |
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Bleeding Gums |
o Yes o No |
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Sore/Ulcer in the Mouth |
o Yes o No |
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3. Cardiovascular |
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Chest Pain |
o Yes o No |
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Calf Pain or shortness of breath with Walking |
o Yes o No |
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Palpitations |
o Yes o No |
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Swelling in the Feet and/or Ankles |
o Yes o No |
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Rapid Heart Rate |
o Yes o No |
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5. Respiratory |
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Exposure to Tuberculosis |
o Yes o No |
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Sudden Onset of Painful and Difficult Breathing |
o Yes o No |
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Wheezing |
o Yes o No |
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Shortness of Breath |
o Yes o No |
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6. Gastrointestinal |
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Acid Reflux/heartburn |
o Yes o No |
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Bloating |
o Yes o No |
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Constipation |
o Yes o No |
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Diarrhea |
o Yes o No |
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Nausea/vomitting |
o Yes o No |
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Change with Bowel Movements |
o Yes o No |
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7. Musculoskeletal |
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Joint Pain/back pain |
o Yes o No |
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Muscle weakness |
o Yes o No |
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Joint Stiffness |
o Yes o No |
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7. Skin |
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Acne |
o Yes o No |
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Atypical Moles |
o Yes o No |
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Breast Tenderness |
o Yes o No |
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Breast Skin Changes/masses |
o Yes o No |
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Nipple Discharge |
o Yes o No |
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8. Neurological |
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Headaches |
o Yes o No |
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Seizures |
o Yes o No |
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Tremors |
o Yes o No |
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Trouble Walking |
o Yes o No |
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9. Hematological |
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Easy Bruising |
o Yes o No |
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Cuts that do not stop bleeding |
o Yes o No |
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Enlarged/Swollen Lymph Nodes |
o Yes o No |
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10. Endocrine |
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Heat/Cold Intolerance |
o Yes o No |
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Excessive Hair Growth |
o Yes o No |
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Abnormal Thirst |
o Yes o No |
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11. Psychiatric |
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Anxiety |
o Yes o No |
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Crying Spells |
o Yes o No |
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Depression |
o Yes o No |
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Feeling Stressed |
o Yes o No |
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Loss of Interest in Pleasurable Activities |
o Yes o No |
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Poor Concentration |
o Yes o No |
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Prolonged Sadness |
o Yes o No |
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Sleep Disturbances |
o Yes o No |
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Suicidal Thoughts |
o Yes o No |
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Date Reviewed: ____________________________________ Physician Signature: ____________________________________