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Welcome
Services
Patient Forms
- Formularios para Pacientes
Hospitals
Our Team
Glossary
FAQ
Blog
Testimonials

Rebecca Johnson History Form

OB/GYN History Form (Rebecca Johnson History Form)

"*" indicates required fields

JORDAN RIVER WOMEN’S HEALTH

OB/GYN History Form

Name*

DOB:*

Date*

MM slash DD slash YYYY

Age*

Height:*

Weight:*

Last Menstrual Period:*

Last Pap Smear:*

History of Abnormal Pap?*

Yes

No

When?

Treatment?*

Colposcopy

Leep

Cryotherapy

Menses/Birth Control:

Age at onset of periods:*

Are your period:*

Regular

Irregular

How often do you get your period?*

Less than 20 days apar

21-30 days

30-40 days

More than 40 days apart

How many days does your period last?*

Less than 2

2-5 days

5-7 days

7-10 days

More than 10 days

How many pads/tampons do you use on heavy days?*

Do you miss work/school monthly?*

Yes

No

Do you spot between periods?*

Yes

No

Do you have pain with your periods?*

Yes

No

Have you had the Gardasil Vaccine?*

Yes

No

Which form of birth control, if any, do you use?*

Vasectomy

Tubal Ligation

Other

Are you currently sexually active?*

Yes

No

Other?

Do you bleed after intercourse?*

Yes

No

Do you have pain with intercourse?*

Yes

No

Have you had discharge for >6 months?*

Yes

No

If so, how long?

Is there odor?*

Yes

No

Itching?*

Yes

No

Do you we yourself with any of the following:*

Coughing

Sneezing

Laughing

Running

Lifting

Do you leak with urge or can’t make it to the bathroom?*

Yes

No

How often do you use the bathroom in a 24 hour period?

Do you have chronic constipation?*

Yes

No

Any recent changes in bowel habits?*

Yes

No

If yes, what change?

Do you have a vaginal bulge?*

Yes

No

Any Nipple discharge?*

Yes

No

Medical History – Patient :

Have you had or do you presently have any of the following?

Anemia*

Yes

No

Anxiety*

Yes

No

Arthritis*

Yes

No

Asthma*

Yes

No

Bleeding Disorder:*

Yes

No

Bleeding Disorder Type:

Blood Clots:*

Yes

No

Blood Clots Type:

Cancer:*

Yes

No

Cancer Type:

Chlamydia:*

Yes

No

When?

Chicken Pox:*

Yes

No

DEXA scan:*

Yes

No

When?

Colonoscopy:*

Yes

No

When?

Depression:*

Yes

No

Diabetes:*

Yes

No

Fibromyalgia:*

Yes

No

Genital Wart:*

Yes

No

Gonorrhea:*

Yes

No

Heart Disease:*

Yes

No

Arrhythmia:*

Yes

No

Herpes:*

Yes

No

HIV:*

Yes

No

High Blood Pressure:*

Yes

No

Kidney Disease*

Yes

No

Lupus:*

Yes

No

Mammogram:*

Yes

No

When? (Mammogram)

Migraines:*

Yes

No

Mood Disorder:*

Yes

No

Sickle Cell:*

Yes

No

Sexually active (ever):*

Yes

No

Thyroid Disease*

Yes

No

Thyroid Disease Type

Family History

Diabetes*

Yes

No

Heart Disease*

Yes

No

Hypertension*

Yes

No

Cancer*

Breast

Uterine

Ovarian

Colon

None

Other:

Surgical History – Patient

Surgical History – Patient*

Date

Procedure

Hospital

Medications

Medications*

Name

Dosage

Frequency

Obstetric History

Have you ever been pregnant?*

Yes

No

if no, proceed to Social History (below)

If yes, how many times have you been pregnant?

Have you ever had an abortion or miscarriage?*

Yes

No

If yes, how many?

How many living children do you have?*

Obstetric History*

Birth Date

Weeks at Delivery

Boy / Girl

Weight

Vaginal/C-Section

Complications

Social History

Do you smoke?*

Yes

No

If yes, How much do you smoke?

Do you drink alcohol?*

Yes

No

If yes, how much do you drink?

Do you use illicit or “street” drugs?*

Yes

No

If yes, what and how much do you use?

Are there other problems you need to discuss with your physician?*

Are you Married?*

Divorced?

Single?

Husband/Significant Other’s name:*

Your Employment:*

Patient Name*

Email*

Signature*

Date*

MM slash DD slash YYYY

Email

This field is for validation purposes and should be left unchanged.