Women's Health Patient Intake Form
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Emergency Contact
Name
Phone Number
Relationship
Medical History
Allergies
Current Medications
Chronic Illnesses / Past Surgeries
Relevant Family Medical History
Gynecological History
First Day of Last Menstrual Period
Usual Length of Cycle (days)
Are you currently using contraception?
Yes
No
If yes, what method?
Any current gynecological issues or concerns?
Obstetric History
Number of Pregnancies
Number of Live Births
Number of Miscarriages
Number of Abortions
Any pregnancy or birth complications?
Lifestyle
Do you smoke?
No
Yes
Former Smoker
Do you drink alcohol?
No
Yes
Do you exercise regularly?
Yes
No
Other notes or concerns