Pelvic/ Obstetric Questionnaire
Please do not complete this form until it's less than one week before your appointment.
Patient's name
*
First Name
Middle (Optional)
Last Name
Birth date
*
/
Month
/
Day
Year
Age
Referring MD
*
2nd MD to get report
Reason your MD ordered this exam
*
Menstrual status
*
Still having periods
Had hysterectomy
Perimenopausal
Went through menopause
First day of your last menstrual period
*
Enter NA if not applicable
In what year did you have hysterectomy or go through menopause?
Number of previous pregnancies
Number of term deliveries
Number of premature deliveries
Number of C-sections
Number of miscarriages
When was your most recent pelvic or obstetrical ultrasound?
Where was your most recent pelvic/OB ultrasound performed?
Do you have a known latex allergy?
*
* YES *
No
Are you pregnant?
*
Yes
No
Date of first positive pregnancy test
/
Month
/
Day
Year
Type of pregnancy test
Urine
Blood
Blood beta-hCG level (mIU/mL)
Were your menstrual cycles regular?
Yes
No
Days between cycles
Due date
/
Month
/
Day
Year
Of your previous babies, what was the highest baby birth weight?
Of your previous babies, what was the lowest baby birth weight
Do you have:
Spotting/bleeding
Pain/cramping
Diabetes
High blood pressure
Prior tubal/ectopic pregnancy
None of the above symptoms or history
If there is a personal or family history of birth defects, what type?
Do you smoke?
Yes
No
Have you had genetic testing?
Yes
No
Any other pertinent information?
Do you currently take:
Tamoxifen, Arimidex, Femara, or similar medication
Hormone replacement
Oral contraceptives
None of these medications
Other pertinent medications
Do you have a history of:
Abnormal bleeding
Heavy bleeding
Endometrial biopsy
Endometriosis
Fibroids
Current IUD
Tubal ligation
Personal or family history of breast or ovarian cancer
None of the above symptoms
What pelvic surgeries had you had?
What pelvic cancers have you had?
Today
/
Month
/
Day
Year
Submit
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