Gynecology Intake Form – Fill Out and Use This PDF

The Gynecology Intake Form is a comprehensive document used to gather essential health information from patients prior to gynecological examinations and treatments. It covers a wide range of topics, including personal and medical history, reproductive health, lifestyle habits, and more, ensuring personalized and informed healthcare. To begin your healthcare journey with thoroughness and care, please fill out the form by clicking the button below.

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Gynecology Intake Form PDF Details

Navigating through a gynecology intake form can feel overwhelming given its comprehensive nature, yet it’s an essential first step toward initiating personalized health care. This detailed form, filled out by the patient before their appointment, covers a wide array of information starting from basic personal data like name, birth date, and contact details to more specific gynecological, medical, and surgical history. It inquires about menstrual history, past pregnancies, and any experiences with illnesses, surgeries, or familial health issues. Additionally, it assesses lifestyle choices, including diet, exercise, and habits such as smoking and alcohol consumption, all of which can significantly impact gynecological health. The form also addresses personal safety questions, reflecting an understanding of the profound impact that interpersonal relationships and social circumstances can have on physical health. This holistic approach ensures a comprehensive understanding of the patient's health status, aiding healthcare providers in delivering tailored medical advice and care. Importantly, it includes space for patients to note any particular concerns or topics they wish to discuss with their physician, underscoring the importance of open communication and patient autonomy in health care decisions. Such thoroughness not only facilitates a robust patient-provider relationship but also enhances the care process, making it as accurate and beneficial as possible.

Question	Answer
Form Name	Gynecology Intake Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	gynecology intake form, gynecology intake, HEMATOLOGIC, seatbelts

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GYNECOLOGY INTAKE FORM

DATE: _______/_______/_______		AGE: _____________________
NAME: ______________________________________________________________	BIRTH DATE: _______ /______/_______
ADDRESS:_________________________________________________________________________________________________
CITY		STATE/ZIP
HOME #: _________________________ CELL #: _________________________ WORK #: _____________________________
PRIMARY CARE MD: _______________________________________________	HEIGHT: __________________________

An advance directive is a document that indicates your medical care wishes if you are unable to make

medical decisions (ie. Coma). Would you like to fill out an advanced directive?

 No  Yes

Anything you want to talk to your physician about:

____________________________________________________________________________________________________________

ALLERGIES

MEDICATIONS

DRUG NAMES

DOSAGE DRUG NAMES

DOSAGE

GYN HISTORY

Menstrual History

What is the first day of your last menstrual period? _____________ How long does it last? ____________

How many days apart are your menstrual cycles starting

from the first day of one cycle to the first day of your next cycle?__________________________________

What age did you start having menses? _____________

When was your last PAP smear? _______________________
Have you ever had an abnormal Pap smear?  No	 Yes	When? ____________
What abnormality? __________________________________
Have you ever been treated for:  Chlamydia	 Gonorrhea		 Genital Warts
 Herpes	 Trichomonas		 Syphilis

Have you ever tested positive for HIV?				 No	 Yes
Did you mother take the drug DES when she was pregnant with you?				 No	 Yes
Are you currently sexually active?	 No	 Yes	 Never
Did you begin sexual activity before 16yo?  No		 Yes		If yes, Age started: _________
Have you had > 5 sexual partners in your lifetime?		 No	 Yes	If yes, how many? _________
Sexual Orientation _______________________________
Are you currently using birth control?	 No	 Yes	 Trying to get pregnant

Current birth control: __________________________________ Are you satisfied with it:  No  Yes

Past Birth control methods:
Condoms		Birth control pills		Withdrawal		Tubal Ligation	
Diaphragm		Patch		Rhythm		Vasectomy	
Vaginal Film		Vaginal Ring		IUD		Essure	

PREGNANCY HISTORY

Number	Number	Number
Total times pregnant	Full term deliveries	Cesarean sections
Miscarriages	Deliveries before 37 weeks	Forceps or vacuums
Abortions	Living children

Describe any special pregnancy problems:

PERSONAL MEDICAL HISTORY

MAJOR ILLNESSES	YES		YES	YES
Diabetes		Heart Disease		Anxiety
High Blood Pressure		High cholesterol		Depression
GI Reflux disease		Hepatitis		Seizures
Other GI disease		Liver problem		Asthma
Fibroids		Kidney infections/stones		Lung disease
Endometriosis		Arthritis		Tuberculosis
Osteopenia		Joint Pain		Thyroid disease
Osteoporosis		Fracture		Clotting disorder
Cancer (Type)
Add others/Explain:

SURGICAL HISTORY

SURGERY	YEAR	SURGERY	YEAR

FAMILY HISTORY

MAJOR ILLNESSES	YES		YES	YES
Diabetes		Heart Disease		Anxiety
High Blood Pressure		High cholesterol		Depression
GI Reflux Disease		Hepatitis		Seizures
Other GI disease		Liver problem		Asthma/
Fibroids		Kidney infections/stones		Lung disease
Endometriosis		Arthritis		Tuberculosis
Osteopenia		Joint pain		Thyroid disease
Osteoporosis		Fracture		Clotting disorder
Cancer (Type)
Add others/Explain:

		SOCIAL HISTORY
		Personal Profile
		Preferred

Occupation: __________________________________ Language: ________________________________

Birth Place: ________________________________________ Ethnicity: ___________________________

Married 	Single 	Divorced  Widowed  Significantly Involved  Domestic Partner 
Education Level: High school  College  Graduate degree  Other 
Exercise:	Yes 	No 

How often __________________________ Type _______________________________________________

Special Diet: Yes  No  Type

_________________________________________________

Hobbies, Interests, Goals: _________________________________________________________________________________

____________________________________________________________________________________________________________

Habits

Smoking:		Yes		No		Packs/day _______________ Years _________			Quit when: _______
Alcohol:		Yes		No		Drinks/day _________ Drinks/week:		________ Quit when:
_______
Drug Use:		Yes		No		Type _________________________ Years ______ Quit when:
______
Caffeine:		Yes		No		Cups per day ______________ Cups per week: _______________
Do you use seatbelts? Yes 						No 	Do you use sunscreen?	Yes 	No 
Do you own guns in your home? Yes 							No  If yes, is it in a secure location?		Yes  No 
							Personal Safety
Yes		No			Has anyone close to you ever threatened to hurt you?
Yes		No			Has anyone ever hit, kicked, choked or hurt you physically?

Yes		No		Has anyone, including you partner, every forced you to have sex?
Yes		No		Are you ever afraid of your partner?
						REVIEW OF SYSTEMS
1. CONSTITUTIONAL					NOTES		7. GENITOURINARY		NOTES
Fever							Abnormal Bleeding	
Chills							Vaginal discharge/ odor	
Fatigue							Vaginal itching/ burning	
Weight Loss							Pelvic pain	
Weight gain							Menstrual cramps	
2. EYES							Painful intercourse	
Changes in vision							Genital lump	
Double vision							Fertility concerns	
3. ENT/ MOUTH							Menopausal concerns	
Ear aches							8. MUSCULOSKELETAL
Ringing in the ears							Muscle weakness	
Sinus problems							Joint stiffness	
Sore throat							Joint pain	
Mouth sores							Joint swelling	
Dry Mouth							9. SKIN/ BREAST
4. CARDIOVASCULAR							Breast pain	
Chest pain							Nipple discharge	
Difficulty breathing on							Breast lumps	
exertion
Swelling of legs							Rash	
Palpitations							Ulcers	
Heart Murmurs							11. PSYCHIATRIC
5. RESPIRATORY							Depression	
Wheezing							Mood swings	
Spitting up blood							Anxiety	
Shortness of breath							Suicidal thoughts	
Cough							Homicidal thoughts	
6. GASTROINTESTINAL							12. ENDOCRINE
Diarrhea							Abnormal thirst	
Constipation							Hot flashes	
Nausea/vomiting							Tremors	
Bloody stool							Cold/ heat intolerance	
Abdominal pain							13. HEMATOLOGIC
Indigestion							Frequent bruising	
Bloating							Cuts do not stop bleeding	
Liver problem/Hepatitis							Enlarged lymph nodes	
7. GENITOURINARY
Blood in urine				
Pain with urination				
Urgency				
Urinary Frequency				
Urinary Incontinence				
11/07 KC

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1. Firstly, once filling in the gynecology intake form, start in the section that has the subsequent blanks:

2. Once your current task is complete, take the next step – fill out all of these fields - DRUG NAMES, MEDICATIONS DOSAGE DRUG NAMES, GYN HISTORY, DOSAGE, Menstrual History What is the, and When was your last PAP smear Have with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

It's simple to make an error when filling out your DOSAGE, consequently you'll want to take a second look before you decide to send it in.

3. In this part, take a look at Have you ever tested positive for, PREGNANCY HISTORY, Number Number Number Total times, Full term deliveries Deliveries, and Cesarean sections Forceps or. Each of these must be taken care of with utmost accuracy.

4. To move forward, this next stage involves completing several empty form fields. These include Number Number Number Total times, PERSONAL MEDICAL HISTORY, MAJOR ILLNESSES YES YES YES, Heart Disease High cholesterol, Anxiety Depression Seizures Asthma, and SURGICAL HISTORY, which you'll find essential to continuing with this PDF.

Osteopenia conclusion process outlined (portion 4)

5. To finish your document, the particular subsection features several additional fields. Entering SURGERY YEAR SURGERY YEAR will certainly conclude everything and you will be done in the blink of an eye!

Osteopenia conclusion process clarified (part 5)

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Gynecology Intake Form – Fill Out and Use This PDF

Gynecology Intake Form PDF Details

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