Women’s Annual Gynecological History Update
Personal Information
Full Name
Date of Birth
Email
Phone Number
Menstrual History
Age at first period
Date of last menstrual period
Are your periods regular?
Yes
No
Any problems with your periods?
Obstetric History
Number of pregnancies
Number of deliveries
Number of miscarriages
Number of abortions
Details (if any)
Contraceptive History
Are you currently using any contraceptive method?
Yes
No
If yes, please specify
Gynecological History
Have you ever been diagnosed with any gynecological conditions?
Have you ever had any gynecological surgeries?
Screenings
Date of last Pap smear
Date of last mammogram
Any abnormal results?
Other Notes or Concerns