New Patient Intake Form
Patient name:
Reason for today’s visit:
Pregnancy History
How many pregnancies have you had?
Please share the results of each:
Full Term	Premature		Other (ectopic, tubal, molar)
Abortion	Miscarriage		Living Children
Any complications during pregnancy, labor, delivery or post-partum period?
o 4° Episiotomy   o C-section   o Post-partum bleeding   o Depression   o Vaginal lacerations   o Forceps
o Other:
Gynecological History
First day of your last menstrual period:
How old were you when your menses started?
Are you still having menstrual periods?				o Yes     o No
If so, periods are:		o Light     o Moderate     o Heavy     o Bleed through protection
How many days between your periods?
How many days of menstrual flow?
Do you have any pain with your periods?				o Yes     o No
Are periods regular?				o Yes     o No
Do you pass any clots in menstrual flow?				o Yes     o No
Do you have more than 35 days in-between periods?				o Yes     o No
Do you get less than 6 periods year?				o Yes     o No
Do you have bleeding in-between periods?				o Yes     o No
Do you have bleeding after intercourse?				o Yes     o No
Do you have a history of anemia?				o Yes     o No
Have you ever had a blood transfusion?				o Yes     o No
Have you ever been diagnosed with fibroids?				o Yes     o No
Have you ever been diagnosed with polyps inside the uterus?				o Yes     o No
Are you suffering from pre-menstrual syndrome (PMS)?				o Yes     o No
Do you have a history of endometriosis?				o Yes     o No
Do you have a history of pelvic pain?				o Yes     o No

Are you sexually active now?			o Yes     o No
With  o one partner, if so, o Male  o Female With  o multiple partners, if so  o Male    o Female     o Both
Do you have any questions about sex you would like to ask?			o Yes     o No
Are you satisfied with your current sexual function?			o Yes     o No
If you answered “no”, how long have you been dissatisfied with your sexual function?
Which of the following problems apply:
Little or no interest in sex			o Yes     o No
Decreased genital sensation			o Yes     o No
Decreased vaginal lubrication			o Yes     o No
Problem reaching an orgasm			o Yes     o No
Problem with pain during sex			o Yes     o No
Other:
Would you like to talk about it with your doctor?			o Yes     o No
Birth control – If using, please indicate if you are presently experiencing side-effects or if you have in the past:
If needed, what is your present method of birth control:
Past method(s) of birth control (select all that apply):
o Nothing   o Pill   o Patch   o Nuvaring  o Rhythm  o Implant  o Condom   o Tubal Ligation  o Vasectomy
o Hysterectomy   o Mirena IUD (progesterone-containing, 5 years)    o Copper T IUD (hormone-free, 10 years)
o Depo-Provera Injections every 3 months   o Essure Hysteroscopic Sterilization    o Other: __________________
Future childbearing plans:  o I do not desire children in the future        o I desire children in the future
o I would like to ask a question about this   o Other:
Date of last Pap Smear: __________________________                                                Result:
Abnormal Pap Smears – Have you ever had an abnormal Pap or Colposcopy?			o Yes     o No
Have you had any treatments to your cervix?
o No   o Cryosurgery   o Laser Surgery   o LEEP   o Conization   o Other ______________________
Have you ever had a sexually transmitted disease?			o Yes     o No
o Chlamydia     o Gonorrhea     o Herpes     o Syphilis     o HIV     o Trichomonas
Would you like to be tested for a sexually transmitted disease today?			o Yes     o No
Do you have frequent yeast infections?			o Yes     o No
Do you have recurrent vaginal infections?			o Yes     o No
Menopause (if applicable) – Age of menopause (last menstrual period)?
Are you currently experiencing:
o Hot Flashes   o Vaginal Dryness   o Sleep Interruptions   o Abnormal/Irregular Periods
oPost-Menopausal Bleeding   o Other: __________________________
Do you experience any of the following:
Loss of urine when coughing, sneezing or laughing?			o Yes     o No
Frequent urination?			o Yes     o No
Pain during urination?			o Yes     o No
Need to urinate with little warning?			o Yes     o No
Do you ever lose urine before reaching the toilet?			o Yes     o No
Difficulty passing urine?			o Yes     o No
Frequent bladder infections?			o Yes     o No
Frequency of nighttime urination:		o 0-1     o 2 or more
Frequency of daytime urination:	o 8 or less     o 9 – 15      o 16+
Do you still feel full after urination?			o Yes     o No
Do you feel pain, pressure, “ball” in the vagina?			o Yes     o No
Do you feel like your bladder or uterus are low/dropped?			o Yes     o No
Have you ever experienced pelvic organ prolapse?			o Yes     o No
Do you have a history of ovarian, cervical or uterine cancer?			o Yes     o No
Past Operations/Hospitalizations Please indicate the year and reason for operation/hospitalization
Medical History
Please list your medical problems (for example, high blood pressure, diabetes, etc):
Allergies to Medications (please list medication and what type of reaction you had):

Current Medications: (please list all medicine and over-the-counter medicine prior to gynecological visit, including hormones, vitamins, and herbs)
Medication Name (Brand/Generic)	Dose	Frequency	Start Date		End Date	Prescribed By		Initials of Reviewer
Social History
Current and Past Alcohol Intake (drinks per week):
Do you have a problem with recreational drugs ?
Have you ever received treatment for substance abuse?							o Yes     o No
If you smoke: number of Cigarettes Per Day:
Past Cigarette Use (years):
Exercise (type, frequency, duration):
Describe your diet:
Are you losing weight?							o Yes     o No
What do you do for work? __________________________________________________ Personal Safety
Do you feel safe at home?							o Yes     o No
Has anyone, including your partner, ever forced you to have sex?							o Yes     o No
Have you ever been sexually, physically or emotionally abused?							o Yes     o No
Health Maintenance and Screening: If you’ve had and know the results
Date and result of last mammogram:				Date: ________________  Result: ______________
Have you ever had an abnormal mammogram, breast ultrasound or breast biopsy?							o Yes     o No
Do you do self breast exams?							o Yes     o No
Date and result of last colonoscopy or sigmoidoscopy (50 +):				Date: ________________  Result: ______________
Date and result of last thyroid function test:				Date: ________________  Result: ______________
Date and result of last cholesterol test:				Date: ________________  Result: ______________
Date and result of last diabetes test:				Date: ________________  Result: ______________
Date and result of last bone density test:				Date: ________________  Result: ______________
Date and result of last HIV test:				Date: ________________  Result: ______________
Date of last HPV vaccine:				Date: ________________  Result: ______________
If you had, did you receive all three shots?							o Yes     o No
Date of last tetanus immunization:				Date: ________________  Result: ______________
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
If yes, please provide name, address and phone number: ______________________________
Family History Parents, Grandparents, Siblings, Children – Please indicate the person(s)
o Breast Cancer
o Ovarian Cancer
o Uterine Cancer
o Colon Cancer
o Diabetes
o High Cholesterol
o High Blood Pressure
o Heart Disease
o Osteoporosis
o Premature Menopause
o Alzheimer’s Disease
o Other: ___________________________________
Review of Systems : Are you experiencing any of the following?
1. Constitutional
Fatigue							o Yes     o No
Fever							o Yes     o No
Unintentional Weight Loss							o Yes     o No
Unintentional Weight Gain							o Yes     o No
2. Ears/Nose/Mouth/Throat
Frequent Nosebleeds							o Yes     o No
Bleeding Gums							o Yes     o No
Sore/Ulcer in the Mouth							o Yes     o No
3. Cardiovascular
Chest Pain							o Yes     o No
Calf Pain or shortness of breath with Walking							o Yes     o No
Palpitations							o Yes     o No
Swelling in the Feet and/or Ankles							o Yes     o No
Rapid Heart Rate							o Yes     o No
5. Respiratory
Exposure to Tuberculosis							o Yes     o No
Sudden Onset of Painful and Difficult Breathing							o Yes     o No
Wheezing							o Yes     o No
Shortness of Breath							o Yes     o No
6. Gastrointestinal
Acid Reflux/heartburn							o Yes     o No
Bloating							o Yes     o No
Constipation							o Yes     o No
Diarrhea							o Yes     o No
Nausea/vomitting							o Yes     o No
Change with Bowel Movements							o Yes     o No
7. Musculoskeletal
Joint Pain/back pain							o Yes     o No
Muscle weakness							o Yes     o No
Joint Stiffness							o Yes     o No
7. Skin
Acne							o Yes     o No
Atypical Moles							o Yes     o No
Breast Tenderness							o Yes     o No
Breast Skin Changes/masses							o Yes     o No
Nipple Discharge							o Yes     o No
8. Neurological
Headaches							o Yes     o No
Seizures							o Yes     o No
Tremors							o Yes     o No
Trouble Walking							o Yes     o No
9. Hematological
Easy Bruising							o Yes     o No
Cuts that do not stop bleeding							o Yes     o No
Enlarged/Swollen Lymph Nodes							o Yes     o No
10. Endocrine
Heat/Cold Intolerance							o Yes     o No
Excessive Hair Growth							o Yes     o No
Abnormal Thirst							o Yes     o No
11. Psychiatric
Anxiety							o Yes     o No
Crying Spells							o Yes     o No
Depression							o Yes     o No
Feeling Stressed							o Yes     o No
Loss of Interest in Pleasurable Activities							o Yes     o No
Poor Concentration							o Yes     o No
Prolonged Sadness							o Yes     o No
Sleep Disturbances							o Yes     o No
Suicidal Thoughts							o Yes     o No

Date Reviewed: ____________________________________     Physician Signature: ____________________________________