Gynecology & Obstetrics | Manhattan, KS

First name

Last name

Middle name

Date of Birth

Email address

Mobile Phone number

Reason for upcoming visit

Preferred pharmacy?

Who is your Primary Care Provider?

Do you have any drug allergies

Yes

No

If yes, what is your reaction?

Please list current medication you are taking, to include over-the-counter medications and vitamins

When was you last Flu shot?

When was your last COVID vaccine?

When was you last Tdap?

Please list any current medical problems you are being treated for

When was your last pap smear?

Do you have a history of abnormal paps?

If yes, what was the result?

First day of your last period.

Duration of your flow?

Are you sexually active?

Are you experiencing any sexual problems?

Have you ever been diagnoses with an STD/STI?

Have you completed the HPV vaccine series?

Have you been diagnosed with PCOS?

Have you been diagnosed with Endometriosis?

Have you been diagnosed or treated for infertility?

When was your last mammogram?

When was your last bone density scan?

Are you currently on hormone replacement therapy?

Are you currently experiencing any urinary issues?

How many total times have you been pregnant?

Out of your total pregnancies, how many were full-term deliveries (38+wks)?

Out of your total pregnancies, how many were premature deliveries?

How many ended in miscarriage?

How many ended in an ectopic pregnancy?

How many ended with elective termination/ abortion?

How many children are still living today?

Do you have any family members with the following cancers?

Of yes above, please list which caner and what relation.

Please list any other medical condition and which family members.

Is your mother still living?

Is you father still living?

What is the highest grade of school you completed?

Are you currently employed?

What is your occupation?

What is your relationship status?

Have there been any changes to your family or social situation?

Do you or have you ever smoked tobacco?

If yes, how much do you smoke?

When did you stop smoking?

Do you or have you used any other form of tobacco or nicotine?

Do you or have you use e-cigarettes or vape?

Do you or have you used smokeless tobacco?

What is your level of alcohol consumption?

Do you or have you used illicit or recreational drugs?

What type of diet are you following?

What is your exercise level?

What is your sexual orientation

Gender identity

Pronouns

Would you like for us to use a different first name?

Please list all surgical procedures and approximate dates:

Do you now have, or have you ever had:

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