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Name of PatientDate of BirthMarital Status |
| OccupationEducation |
| History of Tobacco Use – Current AmountYears of Use |
| Alcohol Use – Current AmountDrug Use – Current Type & Amount |
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OBSTETRICAL HISTORY
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| No. of PregnanciesPremature Births <37 wksMiscarriagesAbortionsEctopicLiving Children |
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GYNECOLOGICAL HISTORY
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| Menstrual History – Age at First PeriodAge at Menopause |
| Regular periodsYesNo Comments |
Vaginal Infection / Sexually Transmitted Infection History: Please check if you have ever had any of the following:
Chronic Yeast Infections TrichomonasChronic Bacterial VaginosisChlamydiaHerpesGonorrheaSyphilisPelvic Inflammatory DiseaseHuman Papilloma Virus (HPV, Warts)Other |
(If you find any of the Sexual History questions particularly offensive, leave blank and discuss with your Provider)
Sexual History: Have you ever had sex? Yes No Age at first sexual experienceNumber of lifetime partners
Are you currently sexually active? Yes No Do you have sex with males females both |
| Contraceptive History: Current method Other methods you have used |
Pap Smear History: Date of last Pap SmearAny history of abnormal Pap?YesNo
Please list any treatments you have had for abnormal Paps |