Women's Health Patient Intake Form
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Emergency Contact Name & Relationship
Emergency Contact Phone
Medical History
Allergies
Current Medications
Medical Conditions / Surgeries
Family Medical History
Gynecologic & Obstetric History
Age at First Period
Date of Last Period
Typical Cycle Length (days)
Gynecologic Conditions (e.g. PCOS, Endometriosis)
Number of Pregnancies
Number of Live Births
Number of Miscarriages
Current Contraception
Date of Last Pap Smear
Are you in menopause?
Yes
No
Other Information
Do you smoke?
Yes
No
Former Smoker
Do you drink alcohol?
Yes
No
Reason for Visit