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MRN:

Patient Name:

Department of Obstetrics and Gynecology
PATIENT HISTORY QUESTIONNAIRE		(Patient Label)


	A
	1. Marital Status: Single Married Long term Relationship	Divorced Widowed

2.Reason for this visit: _____________________________________________

3.Referring Physician: ___________________________

4.Occupation:______________________________________________

5.Preferred phone number: ____________________ confidential voice mails OK: ☐ Yes ☐ No

6.Partner: __________________________________ ☐ None 7. Age of partner: __________

last

first

8. Occupation of partner: ___________

BMENSTRUAL HISTORY(complete even if post-menopausal or no longer having periods)

7.Age at first period: _______ years.

8.If your menstrual periods are regular; periods start every: ___________ days

9.lf your menstrual periods are irregular; periods start every:____ to ____ days (e.g.,12 to 60)

10.Duration of bleeding: _____ days

11.	Does bleeding or spotting occur between periods?					Yes	No
12.	Does bleeding or spotting occur after intercourse?					Yes	No
13.	First day of last menstrual period		________________________________________________________
			month		day	year
14.	Is pain associated with periods? Yes			No	Occasionally
15.	If yes to 14, is it: before menses?			during menses?			both?

C		PREGNANCY HISTORY (All pregnancies)				Have never been pregnant

16. OBSTETRICAL HISTORY INCLUDING ABORTIONS & ECTOPIC (TUBAL) PREGNANCIES

							CHILD
	Place of
Year	delivery	Duration	Hrs. of	Type of	Complications Mother	Sex	Birth	Present
Year	or	Preg.	Labor	Delivery	and/or Infant	Sex	Weight	Health
	or	Preg.	Labor	Delivery	and/or Infant		Weight	Health
	Abortion

DBIRTH CONTROL HISTORY

17. What birth control method(s) do you currently use? _______________________________

ESEXUAL HISTORY

18. Do you have a sexual partner? No

Yes

(Male ☐ Female ☐)

19. Are there concerns about your sexual activity which you may want to discuss with your

doctor?	Yes	No
UCLA Form #11864 Rev. (03/11)		Page 1 of 4

MRN:

Patient Name:

(Patient Label)

FPAST OBSTETRICAL/GYNECOLOGICAL SURGERIES

20. Check any that apply: or

SURGERY

D&C

hysteroscopy

infertility surgery

tuboplasty

tubal ligation

laparoscopy

hysterectomy (vaginal)

hysterectomy (abdominal) myomectomy

None
YEAR	SURGERY	YEAR
	ovarian surgery
	L cyst(s) removed ovarian
	R cyst(s) removed ovarian
	L ovary removed
	R ovary removed
	vaginal or bladder repair
	for prolapsed or incontinence
	cesarean section
	cesarean section
	other (specify)
	______________________

GPAST SURGICAL HISTORY (Not OB/GYN)

21. List all surgeries and their year or

None

Surgeries

Year

HPAP SMEAR/MAMMOGRAM HISTORY

22.	Date of last pap smear: _____________________				YEAR
23.	Have you had abnormal pap smears?	No	Yes	cryotherapy
24.	Have you had treatment for abnormal smears?			laser
	No	Yes		cone biopsy
If yes, what type(s) of treatment have you had?				loop excision (LEEP)

25. Date of last mammogram: _______		_______
	month	year
26. Have you had an abnormal mammogram?			No	Yes
OTHER PAST GYNECOLOGICAL HISTORY
27. Check any that apply: None		Venereal warts		Herpes – genital		Syphilis
Pelvic inflammatory disease	Endometriosis			Chlamydia	Gonorrhea
Vaginal infections Other ______________________________________
UCLA Form #11864 Rev. (03/11)						Page 2 of 4

MRN:

Patient Name:

			(Patient Label)


I	PAST MEDICAL HISTORY Check any that apply: or		None
Arthritis		Kidney Disease	Asthma
Diabetes:		Gallstones	Emphysema
	Diet controlled	Liver Disease	Bronchitis
	Pill controlled	(including hepatitis)	HIV+
	Insulin controlled	Epilepsy	Eating Disorder
High blood pressure		Blood Transfusions	Other: _________
Heart disease		Thyroid disease

JCURRENT MEDICATIONS (Include dose (amount) per day)

Medication	Dose	Frequency

KDO YOU CURRENTLY?:

28.	Smoke	No	Yes	_____ packs/day
29.	Use alcohol No		Yes __ wine (glasses/day); __ beer (bottles/day); __ hard liquid (oz./day)
30.	Use illicit drugs		No	Yes	___________ type ______________ amount
31.	Exercise:		Type: _________________ How often ______________________

LDRUG ALLERGIES

32. No Yes

List:

_________________________________________________________________

MFAMILY HISTORY

Diabetes

Ovarian Cancer

Heart Disease	Breast Cancer	Other
Endometrial Cancer	Colon Cancer	___________________
		___________________

If “yes” to any, please list affected relatives

____________________________________________ _________________________________________

None of the above.

UCLA Form #11864 Rev. (03/11)

Page 3 of 4

MRN:

Patient Name:

(Patient Label)

NOTHER SYMPTOMS Have you had recent?:

weight loss	hair growth	none of the above
weight gain	hair loss	Other
change in energy	change in urinary function
change in	hot flushes/flashing
exercise tolerance	breast discharge

NOTE: Fill out Section “O” only if you are pregnant or planning to be pregnant in the near future.

Have you or the baby’s father or anyone in your families ever had any of the following:

Down Syndrome (Mongolism)? If yes, who?_____________________________________

Other Chromosomal abnormality? If yes, specify _________________________________

Neural tube defect (spina bifida, anencephaly)? If yes, who? ________________________

Hemophilia or other coagulation abnormality? If yes, who? __________________________

Muscular Dystrophy? If yes, who? _____________________________________________

Cystic Fibrosis? If yes, who? _________________________________________________

If you or the baby's biological father are of Jewish ancestry, have either of you been screened for

Tay-Sachs disease?
Father	Result ____________________________________
Mother	Result ____________________________________
If you or the baby's biological father are of African ancestry, have either of you been
screened for Sickle cell trait?
Father	Result __________________________________
Mother	Result __________________________________
If you or the baby's biological father are of Italian, Greek, or Mediterranean background,
have either of you been tested for B-thalessemia?
Father	Result __________________________________
Mother	Result __________________________________
If you or the baby's biological father are of Philippine or Southeast Asian ancestry, have
either of you been tested for A-thalessemia?
Father	Result ___________________________________
Mother	Result ___________________________________
____________________________________________		_____________	_________
PATIENT SIGNATURE		DATE	TIME
____________________________________________		_____________	_________
PHYSICIAN SIGNATURE		DATE	TIME
UCLA Form #11864 Rev. (03/11)			Page 4 of 4

Question	Answer
Form Name	Ucla Form 11864
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	ob history form sss, obstetrical history form, sss ob history form, complete obstetrical history

Ucla Form 11864 – Fill Out and Use This PDF

Ucla Form 11864 PDF Details

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