Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
OB/GYN Intake Form
OB/GYN Patient Intake Form Please complete this confidential form before your appointment. All information is protected and helps your provider deliver the best possible care.
Full Name *
Date of Birth *
____ / ____ / ________
Email Address *
Phone Number *
Emergency Contact Name *
Emergency Contact Phone *
Reproductive Health & Medical History Please answer the following questions about your reproductive and general health history.
Reason for Visit *
Date of Last Menstrual Period
____ / ____ / ________
Is Your Menstrual Cycle Regular? *
- Yes
- No
Number of Pregnancies *
Number of Live Births *
Are You Currently Pregnant? *
- Yes
- No
- Unsure
Current Birth Control Method *
- None
- Oral Contraceptive
- IUD
- Implant
- Condom
- Other
Date of Last Pap Smear
____ / ____ / ________
Any Abnormal Pap Results? *
- Yes
- No
Any Breast Concerns? *
- Yes
- No
Gynecological Symptoms
- Pelvic Pain
- Abnormal Bleeding
- Vaginal Discharge
- Hot Flashes
- Urinary Issues
- None
History of Sexually Transmitted Infections? *
- Yes
- No
Surgical History
Current Medications
Allergies
Family History
- Breast Cancer
- Ovarian Cancer
- Cervical Cancer
- Uterine Cancer
- Endometriosis
- None
OB/GYN Intake Form template from formisoft.com. formisoft.com/intake-templates/obgyn-intake