Women's Health Gynecological History Form
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Gynecological History
Age at first period
Date of last period
Are your periods regular?
Yes
No
If no, please explain
Cycle length (days)
Bleeding duration (days)
Any bleeding between periods?
Yes
No
Pain with periods?
Yes
No
If yes, severity or comments
Obstetric History
Number of pregnancies
Number of births
Number of miscarriages
Number of abortions
Any complications?
Contraception & Sexual Health
Current contraception method
Are you sexually active?
Yes
No
History of sexually transmitted infections (STIs)?
Yes
No
If yes, details
Medical History
Previous gynecological surgeries or procedures
Any known gynecological conditions? (e.g., endometriosis, fibroids, PCOS)
Last Pap smear date
Last mammogram date
Other relevant medical history
Family History
Family history of reproductive cancers?
Yes
No
If yes, please specify
Other relevant family history
Comments / Additional Information