St. Louis Womens Health

Gynecology Visit (not pregnant)
Please fill out the form below and hit the Submit button at the bottom.
Patient Name	Age	Date 2/22/2012

Place of employment

Reason for visit

Review of Symptoms (Please check any symptoms that you have now or have had recently.)

Fever	Weight Gain	Weight Loss	Excessive Fatigue
Rashes	Dry Skin	Intolerance to Cold	Hair Loss
Eye Redness	Blurred Vision	Double Vision
Problems Hearing	Dizziness	Sinus Pain	Trouble Swallowing
Chest Pain	Palpitations	Faintness
Coughing	Wheezing	Sputum	Shortness of Breath
Bronchitis	Pneumonia	Tuberculosis
Breast Lumps	Nipple Discharge	Breast Pain
Nausea	Vomiting	Diarrhea	Constipation
Urinary Frequency	Pain with Urination	Incontinence
Muscle Pain	Joint Pain	Weakness
Bruising	Phlebitis	Excessive Bleeding	Anemia
Headaches	Moodiness	Depression	Anxiety	Sleep Disturbances
Vaginal Itching	Burning	Odor
Vaginal Discharge if Yes, what color?		White	Yellow	Green

(Please check any illness that you have now or have had recently.)
High Blood Pressure
Heart Disease
Stroke
Cancer
Diabetes Mellitus
Thyroid Disease
Osteoporosis
Asthma
Arthritis
Transfusion
Glaucoma
Blood Clots

Established Patient: Yes No (New patients - Please fill out an additional Medical History Form)

Are there any changes in your Medical/Surgical or Obstetric History since your last visit? Yes No

FAMILY HISTORY (Check all that apply)
Breast CancerColon CancerOvarian CancerHeart DiseaseOsteoporosisDiabetesElevated Cholesterol

MENSTRUAL HISTORY
Age at first period Menopausal: Yes No
First Day of Last Period
Period Interval in days (eg 26 days, 28 days, 30 days)
Number of days bleeding
Cramps: NoneMildModerateSevere

Premenstrual Symptoms (Please Check)
MoodinessIrritability
TensionAnxiety
Breast PainBloating
HeadachesHeaviness
Depressed MoodFeeling Overwhelmed

OBSTETRIC HISTORY
Number of Pregnancies: Living Children: Premature Babies: Miscarriages: Abortions:
Problems Conceiving: Yes No

SEXUAL HISTORY (Please check)

Have you ever had vaginal sexual intercourse?	Yes No
Have you recently had sex with a new partner?	Yes No
Are you sexually active now?	Yes No
Onset of sexual activity under 16 years of age?	Yes No
Five or more sexual partners?	Yes No
History of a sexually transmitted disease?	Yes No
Absence of three normal pap smears in a row>	Yes No
History of abnormal pap smears?	Yes No

SOCIAL HISTORY (Please check)

Do you smoke?	Yes	No	Amt	Yrs
Do you drink alcohol?	Yes	No	Amt	Yrs
Do you drink coffee?	Yes	No	Amt	Yrs
Do you use street drugs?		Yes	No
Mother used DES in Pregnancy?		Yes	No

Treatment: Date of Treatment:

CONTRACEPTION
Current Method: Name of Birth Control: Past Methods:

Medications (Please list all medications including over the counter, calcium, vitamins, you are currently taking with dosage and frequency)

Please list any known medications that you are allergic to