Gynecology/Annual Physical questionnaire

Please complete and bring this questionnaire before your first prenatal visit and bring it with you. We will review it with you.

YOUR NAME:

_____________________________________________________

 

Allergies/Reactions to medications Do you any allergies /reactions to medications Yes No Please specify if yes and what type of reaction ____________________________

 

Would you like to be screened for sexually transmitted diseases (STD's)

HIV, Gonorrhea,Chlamydia? Yes No

Do you want to go over the breast exam? Yes No

Do you have any present health concerns

or anything you want to discuss? Yes No

If yes: ___________________________________________________

GYNECOLOGICAL HISTORY

How old were you when you had your first period ______

how frequently do your periods come? Every ____days

How long do your periods last? _____Days.

When did your last period start? ________________

Do you experience cramping with your periods? Yes No

If yes, when during your cycles do you have pain (check all that apply):

Before During After

How would you describe the cramps? Mild Moderate Severe

Do you take often take pain medication for the cramps? Yes No

If yes, specify : _____________________________

Do you bleed or spot between periods? Yes No

If yes, please describe: ________________________________

Have you ever had an abnormal Pap smear result? Yes No

If yes, what therapy was required :

Cryotherapy(freezing of cervix) Laser therapy Cone biopsy LEEP

Other: _______

Have you ever had any of the following infections involving any part of the reproductive tract

(vagina, cervix, uterus, ovaries)? Yes No

If yes, which one(s) of the ones below:

Chlamydia Trichomonas Gonorrhea Herpes Genital warts

What treatment did you receive? ____________________________

Your Current sex partner(s) is/are Male Female none

Do you have concerns with your sexuality Yes No

Do you have pain with intercourse? never sometimes frequently always

If yes, does the pain remain in your lower abdomen after intercourse if over ? Yes No

If yes, for how many minutes? ______

If you are trying to conceive please answer the following questions

How frequently do you and your partner have intercourse? _____ per week/Month (circle)

How frequently do you and your partner have intercourse around ovulation? ____ per month

Do you usually use lubrication during intercourse? Yes No

If yes, please specify:_____________________________

What type of contraception do you use presently ( if applicable)?

Contraceptive pills Condoms IUD Foam/Sponge Rhythm Withdrawal

Other ________________________

What type of contraception have you used in the past ( if applicable)?

Contraceptive pills Condoms IUD Foam/Sponge Rhythm Withdrawal

Other ________________________

Do you know if your mother took DES when she was pregnant with you? Yes No

Do you have any family members who have or who have had one of the

following Ob/gyn problems:

Endometriosis Breast Cancer Ovarian cancer Uterine cancer Cervical cancer

If yes, please specify: _______________________________________________________

OBSTETRICAL HISTORY

Have you ever been pregnant ?

(including elective terminations, miscarriages, births)? Yes No

Date_________________________________________________________________

outcome ______________________________________________________________

how long to conceive ____________________________________________________

did you have infertility treatment? ___________________________________________

any pregnancy complications?______________________________________________

Past Medical History

Indicate whether you have had any of the following medical problems, with dates:

Alcoholism ___________ Heart disease/Heart attack ________

High blood pressure ___________ Depression _______________

High Cholesterol ______ Stroke _________________

Thyroid problem ____________________ Diabetes ______________

Cancer (specify what type) _______________

blood transfusions (specify when) ____________

Hepatitis (specify type) ____________________

Other Medical problems (specify) ____________

Surgeries in the past (specify type and date) (1) ___________________

(2) _________________ (3) _____________(4) ________________

Family History

Is there any family history of the following? Please indicate who had the condition:

Alcoholism ________ Heart disease/Heart attack ________ High blood pressure __________

Depression ______________________ High Cholesterol ______ Stroke ________________

Thyroid problem __________________ Diabetes _________________________

Cancer: Melanoma _____________ Breast____________________Colon ___________

Prostate ________________ Uterus _________________ Cervix _______________

Ovary __________________ other types of Cancers _______________

Blood transfusions (specify when) ____________ Hepatitis _______________

Other Medical problems (specify): ___________________

Social History

Birth place : _________________ Education: _________________

Occupation:_________________________________________

Relationship/ Marital status: _________ Number of children (if any) and what age: ________________

Who lives at home with you? _________________

Is violence at home a concern for you? Yes No

Have you ever been abused? ___________ Yes No

Review of Symptoms

Do you any recent problems with any of the following? Please circle all that apply:

Endocrine : fevers/chills/sweats, unexplained weight loss/gain, Change in energy,

excessive thirst or urination

Eyes : Change in vision

Ears/nose/Throat: Difficult hearing/ringing in ears, teeth or gum problems

Respirator y: Cough, wheeze/shortness of breath,

Breast/Chest : Breast lump/nipple discharge

Gastrointestinal: Abdominal pain, blood in bowel movement, nausea/vomiting/diarrhea

Cardiovascular : Chest pain, discomfort, leg pain with exercises/palpitations

Genito/uterinary : nighttime urination, leaking urine

Neurological : headache, dizziness/light headedness, numbness, memory loss

Musculo -skeletal : Muscle/joint pain, loss of coordination

Allergy : hay fever/allergy

Skin : skin sore, rash, change in mole

Psychiatric : anxiety/stress, problems with sleep, depression Blood: easy bruising/bleeding

Habits

Do you drink ALCOHOL? Yes No Drinks/week _____

Is your alcohol use a concern for you or others? Yes No

Do you use TOBACCO now? Yes No cigarettes/day _____ for how long? _____yrs

Are you interested in quitting Yes No

Did you use TOBACCO in the past? Yes No cigarettes/day _____

for how long? _____yrs

when did you quit? ______

Do you or did you use any RECREATIONAL DRUGS

YES NO ____________________________________________

Medications

What current prescription and non-prescription medication are you now taking .

Please include dose: Do you need a refill for any of these medications? Yes No

If yes, please specify which one(s) and what pharmacy: ________________________

Health Maintenance:

Do you EXERCISE regularly Yes No if yes, what kind: ______________________

How long: ______________min how often per week ________times

How would you rate your DIET? Good Fair Poor

Are you satisfied with your weight? Yes No

Do you do REGULAR BREAST EXAMS? Yes No

WHEN was your most recent:

Pap smear ________ Mammogram _______ Cholesterol test ________TSH __________

Glucose _________DEXA (bone scan)

Tetanus booster _____ Flu shot ______ sigmoidoscopy ______ Hepatitis B vaccine _______

Stool test for Blood _________ TB Skin test (PPD) ______ HIV test _______

Pneumonia vaccine _____Exam by an eye doctor _____ Dental check up _______