Female Medical Questionnaire
New Patient Questionnaire
Date
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Month
-
Day
Year
Date
Patient
First Name
Last Name
Age:
DOB
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Month
-
Day
Year
Date
Partner
First Name
Last Name
Age:
DOB
-
Month
-
Day
Year
Date
PLEASE check all that apply
Jewish- Ashkenazi
Jewish-Sephardic
French Canadian
Mediterranean
Cajun
Middle Eastern
Latina/o
African American
American Indian
Native Alaskan/American
Asian
Native Hawaiian
White
Occupation:
Contact Name
Emergency Contact:
Please enter a valid phone number.
Circle - Married or Single
Married
Single
Email:
example@example.com
Home Phone #:
Please enter a valid phone number.
Cell phone #:
Please enter a valid phone number.
Telephone
Please enter a valid phone number.
Pharmacy Name:
Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
MEDICATIONS: Please list any medications you take, including over-the-counter.
REVIEW of SYSTEMS
Yes
No
Weight Increase
Weight Decrease
Pelvic Pain
Abnormal Vaginal bleeding
Bowel changes
Painful periods
Abnormal hair growth
Have you ever had a problem conceiving with another partner?
How long have you been having unprotected sexual intercourse?
How long have you been trying to conceive?
MEDICAL /FAMILY HISTORY - Please check if you or a blood-relative have had any of the following:
Type a question
Myself
Family
Anemia
High blood pressure
High Cholesterol
Heart Disease
Stroke
Diabetes
COPD / Emphysema
Asthma
Thyroid problems
Mental illness
Depression
Anxiety
Eating Disorder
Migraine headaches
Urinary tract infection
Lupus
Seizures
History of TB disease
Liver disease
Gall bladder
Blood clots
Blood transfusion
Breast cancer
Colon cancer
Ovarian cancer
Genetic Disease
Other cancer, please specify
ALLERGIES
If you have any allergies, please list and indicate reaction
SURGICAL HISTORY
Please list and surgeries, including the year
Please list and hospitalizations, including the year
Prior Fertility Testing and SEXUAL HISTORY
Yes
No
Ultrasound
Fertility Pills
HSG (tubes tested)
Fertility injections (IUI)
Surgery
Insemination (IUI)
Fertility Blood Work-up (Labs)
In vitro fertilization (IVF)
Is/Are your partner(s)...
Male
Female
Both
PERSONAL/SOCIAL HISTORY
Do you use tobacco products?
Yes
No
How much?
Do you drink alcohol?
Yes
No
How many per week?
Do you drink caffeine?
Yes
No
How much daily?
Do you exercise?
Yes
No
# Times/week:
Type:
Do you use illicit drugs?
Yes
No
Which drugs?
GYNECOLOGICAL HISTORY
Have you been vaccinated for Human Papilloma Virus?
Yes
No
Last Pap Smear:
Last Mammogram:
Last Colonoscopy Year:
Cone / Leep / Cervical ProceduresYear?
Any personal history of:
Yes
No
Abnormal Pap Smear
Sexually Transmitted Diseases
Uterine Fibroids
Endometriosis
Infertility
MENSTRUAL HISTORY
First day of last period?
Age at first menstrual period?
How often do you get your menses?
Number of days that you bleed?
Describe the amount of menstrual flow (per day): Tampons
Describe the amount of menstrual flow (per day): Pads
How many tampons or pads do you use on your heaviest day?
Do you bleed after intercourse?
Yes
No
Do you bleed between your periods?
Yes
No
Do you experience pain with your period?
Yes
No
Do you have pain with bowel movements during your period?
Yes
No
OBSTETRICAL HISTORY
Please provide the number of...
Pregnancy(ies)
Vaginal Birth
Living Children
C-Section(s)
Miscarriage(s)
Ectopic
Abortion(s)
Signature
Clear
Submit
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