MUSKOGEE WOMEN'S CLINIC GYNECOLOGIC INTAKE HISTORY
Name: _____________________________________________  Date: __________  DOB: ________
Reason for Today's Visit:			_____________________________________________
Last Menstrual Period:			__________________
MEDICAL ILLNESSES                                      OPERATIONS/HOSPITALIZATIONS		YES	NO	LIST ALL OPERATIONS AND HOSPITALIZATIONS
Asthma				REASON				DATE
Pneumonia
Chronic Lung Disease
Kidney Infections/stones
Tuberculosis
Venereal Disease
Heart trouble/murmur
Diabetes
High Blood Pressure				LIST ALL CURRENT MEDICATIONS
Stroke
Hepatitis
Cancer
Ulcers
Anemia/blood transfusion				OB/GYN HISTORY				NUMBER
Seizures/convulsions				Births
Thyroid Disease				Miscarriages
Arthritis/Joint Pain				Abortions
Fracture				Living Children
WHAT METHOD DO YOU USE FOR BIRTH CONTROL? (EXAMPLE:  BILL CONTROL PILLS, TUBAL, ETC.)
DRUG ALLERGIES?		_____________________________________________________
FAMILY HISTORY				SOCIAL HISTORY
ILLNESS		YES	RELATIVE		NO      YES
Diabetes				Smoking		PACKS PER DAY _____ YEARS ___
Stroke				Alcohol		DRINKS PER DAY ___ PER WEEK ___
Heart Disease							NO      YES
High Blood Pressure				Do you exercise regularly?
Breast Cancer				Have you ever used street drugs?
Colon Cancer				Any family problems?
Ovarian Cancer				Any abuse or violence?
				Any sexual problems?
MEDICARE "HIGH RISK" CRITERIA							YES	NO
Have you been treated for Vaginosis, Genital Warts, Chlamydia, Herpes, Trichomonas
Have you had a Pap smear in the last 7 years?
Have you ever had an abnormal Pap Smear Test?
Did you begin sexual activity before you were 16 years old?
Have you had more than 5 sexual partners in your lifetime?
Have you ever tested positive for the HIV virus?
Did your mother take the drug DES when she was pregnant with you?
Last Mammogram:				Last Dexa:
Last Pap Smear:
REVIEW OF SYSTEMS
Please check (x) if you are having a problem with any of the following:
1.  Constitutional				8.  Musculoskeletal
Weight Loss				Muscle Weakness/aches
Weight gain				9.  Skin/Breast
Fever				Pain in Breast
Fatigue				Discharge
2.  Eyes				Masses
Double Vision				Rash
Spots before eyes				Breast Tenderness
Vision changes				10.  Neurological
3.  ENT/Mouth				Dizziness
Ear aches				Seizures
Ringing in ears				Numbness
Sinus Problems				11.  Psychiatric
Sore Throat				Depression,Anxiety
Mouth Sores				Frequent crying
4.  Cardiovascular				12.  Endocrine
Painful Breathing				Dry Skin
Chest Pain				Abnormal Thirst
Difficult breathing on exertion				Hot Flashes
Swelling of legs				13.  Hematologic/Lymphatic
Palpitations of heart				Bruises, frequent
5.  Respiratory				Enlarged lymph nodes
Wheezing				14.  Allergic/Immunologic
Spitting up blood				Allergies
Shortness of breath				Drugs, other
cough, chronic
6.  Gastrointestinal
Diarrhea, frequent				Signature Of Patient : __________________________________
Bloody stool
Nausea/Vomiting				Completed by:     Patient
Constipation					Office Nurse
7.  Genitourinary					Physician
Blood in Urine
Pain with Urination
Urgency				Physician Signature:  ___________________________________
Frequency of Urination
Stress Incontinence				Date reviewed by Physician with patient:  ______________
Abnormal Periods
Painful Intercourse
Pelvic Pain
Vaginal Discharge
ANNUAL REVIEW OF HISTORY
Date reviewed: ________________________  Physician Signature:  _________________________
Date reviewed: ________________________  Physician Signature:  _________________________
Date reviewed: ________________________  Physician Signature:  _________________________
Date reviewed: ________________________  Physician Signature:  _________________________