GYNECOLOGICAL HISTORY Last Menstrual Period: Method of Birth Control: Age of 1st menstrual period: Menses last days and come every days : heavy medium light Last Pap: If any abnormal paps, when and how was it treated: Last mammogram: Where: Any abnormal mammograms and when: Breast procedures/ Ultrasound/ MRI? Breast Implants? Type: Lifetime sexual partners 1-5 6-20 > 20 Condition When? Date First Date Taking Office Use Only Diagnosed Resolved Medication? Genital Infections: Bacterial Vaginosis Gonorrhea HPV Chlamydia Herpes Uterine fibroids Now the past In  Ovarian Cyst Now the past In  Vaginal Dryness Now the past In  Decreased Sex Drive Now the past In  Painful intercourse Now the past In  Irregular Bleeding Now the past In  Painful Periods Now the past In  Other: Now the past In  MALES: Date Date Taking Office Use Only Condition When? Diagnosed Resolved Medication? Reproductive None  Genital Infections: Bacterial Vaginosis Gonorrhea HPV Chlamydia Herpes Other: Prostate Problems Now the past In  Decreased Sex Drive Now the past In  Erectile Dysfunction Now the past In  Other: Now the past In  Patient Signature Date Reviewed by Provider Date Reviewed by CRC (if applicable) Date
GYNECOLOGICAL HISTORY Last Menstrual Period: Method of Birth Control: Age of 1st menstrual period: Menses last days and come every days : heavy medium light Last Pap: If any abnormal paps, when and how was it treated: Last mammogram: Where: Any abnormal mammograms and when: Breast procedures/ Ultrasound/ MRI? Breast Implants? Type: Lifetime sexual partners 1-5 6-20 > 20 Condition When? Date First Diagnosed Date Resolved Taking Medication? Office Use Only Genital Infections: Bacterial Vaginosis Gonorrhea HPV Chlamydia Herpes Uterine fibroids Now In the past  Ovarian Cyst Now In the past  Vaginal Dryness Now In the past  Decreased Sex Drive Now In the past  Painful intercourse Now In the past  Irregular Bleeding Now In the past  Painful Periods Now In the past  Other: Now In the past  MALES: Condition When? Date Diagnosed Date Resolved Taking Medication? Office Use Only Reproductive None  Genital Infections: Bacterial Vaginosis Gonorrhea HPV Chlamydia Herpes Other: Prostate Problems Now In the past  Decreased Sex Drive Now In the past  Erectile Dysfunction Now In the past  Other: Now In the past  Patient Signature Date Reviewed by Provider Date Reviewed by CRC (if applicable) Date
clinic_patient_registration_packet_2018.docx