Microsoft word - nb-obgyn-healthquestionnaire.doc

Newport Beach OB/GYN Medical Group, Inc. (use “tab” on keyboard to go from field to field)

This information is confidential. We appreciate your cooperation in completing this form thoroughly. Please print legibly. Health Questionnaire

Name:

Marital Status: Single Married Partnered Divorced Separated Widowed Other
Obstetrical History:
Do you wish more pregnancy? How many children living?
Gynecologic History:
Menstrual periods come every days and last for days. Any recent changes in your periods? If ‘yes’ to any of above, please explain: Preventative Health:
Do you have annual check-ups with a family doctor of internist? Sexuality:
Do you have questions regarding sexuality?
Birth Control:
Current method of contraception (check one):
Infections:
Have you ever had a sexually transmitted disease?
Menopause:
Do you take hormone replacement therapy? Have you had any vaginal bleeding since menopause? Explain any other gynecological problems or questions:
Past Medical History:
Allergies:
Medications you are taking – including birth control pills:
Operations: (List Date, Type, Hospital and any Complications)

Medical Illness or Problems (Please list):
Have you had problems with any of the following conditions?
Family History:
Have any of your blood relatives had:

Are you adopted? yes no
Review of Systems:
Do you have or have you ever had:
Problems with your eyes, ears, nose, throat? Problems breathing of shortness of breath? Problems with your heart, mitral valve prolapse, rheumatic fever, chest pain irregular heart beat, or abnormal electrocardiogram? Problems with fibrocystic breast tumors or discharge from your nipples? Problems with your bowels, change in bowels habits, diarrhea, constipation, hemorrhoids or bleeding with bowel movements? Problems with urination, kidney or bladder infection, or accidental loss of urine? Problems with pelvic pressure, low back pain or a sensation of pelvic organs Problems with excessive thirst, frequent urination, feeling extremely cold or Arthritis, thrombophlebitis, easy bruising or varicose veins? Change in voice, increased facial or body hair? Depression, anxiety or the need for psychological counseling or psychiatric care? Have you used IV drugs, had a partner who was bisexual or used IV drugs, or had more than 10 sexual partners in your life? Weight change of more than 20lbs. over the past year, or a history of an eating disorder such as bulimia, anorexia nervosa, or over eating?
Social History:

Optional:
Have you been physically or mentally abused by your spouse, partner, parent, etc…? Have you been sexually abused or raped? How may sexual partners have you had in your life? What is your ethnic background?

Source: http://www.nb-obgyn.com/paperwork/nb-obgyn-healthquestionnaire.pdf