Initial Gyn Clinic Visit Patient Questionnaire
Please help us to provide the best health care for you by completing this form.
If you have any questions about it, your health care provider will be glad to assist you.
Menstrual History
Age your periods began: _______
When you are not using a hormonal method of birth control (pill, patch, ring, shot),
a) How many days between the first day of one period and the first day of the next? ______
b) How many days does the flow last? ______ Is it light ______; moderate ______; heavy ______?
c) Menstrual symptoms: none ______; cramps ______; severe pain ______; bloating ______;
breast tenderness ______; severe emotional changes ______; nausea/vomiting ______; other ______.
d) Medication(s) used for menstrual symptoms: ____________________________________.
e) Missed periods: never ______; rarely ______; occasionally ______ frequently ______.
f) Bleeding between periods: never ______; rarely ______; occasionally ______ frequently ______.
Gynecologic History
Yes
Clinician Comments:
No
xxx
xxx
xxx
xxx
Is this your first gynecologic exam?
If no, date of last Pap test: __________
Abnormal Pap test
Positive HPV test
If yes, date of positive test: __________
Have you received the HPV vaccine (Gardasil)?
If yes, please provide dates of injections:
1 __________ 2 __________ 3 __________
Genital herpes
Genital warts
Chlamydia or gonorrhea
Pelvic inflammatory disease (PID)
Other sexually transmitted infection
Frequent vaginal infections
Frequent urinary infections
Pelvic or abdominal surgery
Breast problems or surgery
Other gyn condition: ________________
Sexual History
Yes
No
xxx
xxx
Have you ever had vaginal intercourse?
At what age did you first have vaginal intercourse? __________
Are you currently in a sexual relationship?
If yes, are you having vaginal intercourse with your current partner?
Do you engage in other sexual practices with your current partner?
Are you experiencing any pain or other difficulties with sexual activity?
Have you ever been hurt or frightened during sex?
Pregnancy History
Ever pregnant? Yes_____; No_____. Age at first pregnancy______.
Number of pregnancies_____; Number of living children_____.
List all pregnancies: year, outcome, complications
University of Virginia
Department of Student Health
Gynecology Clinic
Name: _______________________
Date of Birth: __________________
Today’s Date: _________________
Contraceptive History
Please include all the methods you have used or are using:
Method
Now
Past
Dates of use
Condom
Birth control pills
Brand: _________
DepoProvera
Lunelle
Patch
Ring
IUD
Diaphragm
Cervical cap
Spermicide
Withdrawal
Natural family
planning
Other: ___________
Problems or reasons for stopping
Personal and Family Health History
Please check the appropriate column if you or a family member has ever had any of the following.
Condition
Self
Family
Clinician comments
Cancer
Heart disease
Stroke
High blood pressure
Diabetes
Thrombosis/embolism (blood clot)
Seizures
Migraines
Kidney disease
Liver disease
Gall bladder disease
Brain or neurologic disease
Bleeding or clotting disorder
Thyroid problem
Elevated cholesterol
Depression
Allergies
XXXX
Health Habits
Past
Currently
Never
Cigarettes: # per day_______
Alcohol: # of drinks per week _____
Exercise: # of hours per week _____
Over or under weight
Problems with sleep
Emotional problem or difficulties
Student’s signature: _____________________________
□ I have reviewed the above information with the student: ______________________________
(Clinician)
1/21/2014