OB/GYN intake covers a full medical history plus a detailed reproductive history, and the questions are sensitive. A good form is thorough without being exhausting, and uses conditional logic to show each patient only what applies.
Demographics and Contact Information
Full name, date of birth, address, phone, email, emergency contact. Include preferred pharmacy and referring provider, if applicable.
Reason for Visit
Let patients indicate the primary reason:
- Annual well-woman exam
- Pregnancy confirmation or prenatal care
- Contraception consultation
- Irregular periods or menstrual concerns
- Pelvic pain
- Fertility consultation
- STI screening
- Menopause management
- Other gynecological concern
This answer should drive the rest of the form: prenatal care and contraception counseling need different follow-up sections.
Menstrual History
Core reproductive health data:
- Age at first period (menarche)
- Date of last menstrual period (LMP)
- Cycle length and regularity
- Duration of bleeding
- Flow heaviness (light, moderate, heavy)
- Painful periods: severity and impact on daily activities
- Intermenstrual bleeding or spotting
- Menopause status, if applicable (last period date, symptoms)
Pregnancy History
Use the obstetric shorthand that clinicians understand, but make it patient-friendly:
- Number of pregnancies (gravida)
- Number of full-term deliveries
- Number of preterm deliveries
- Number of miscarriages or abortions
- Number of living children
- For each prior pregnancy: year, delivery method (vaginal/C-section), complications, birth weight
Show this section only if the patient reports prior pregnancies.
Contraception
- Current method (or none)
- Past methods used and reasons for discontinuation
- Interest in changing or starting contraception
- Satisfaction with current method
Sexual Health and STI Screening
Handle this section with clear, neutral language:
- Sexually active (yes/no)
- Partners (male, female, both)
- Number of partners in the past 12 months
- History of STIs (type, treatment, year)
- Date of last STI screening
- Concerns about current symptoms
Pap Smear and Cancer Screening
- Date of last Pap smear
- Results (normal, abnormal, ASCUS, LSIL, HSIL)
- History of abnormal Pap results
- History of colposcopy or LEEP procedure
- HPV vaccination status
- Date of last mammogram (age-appropriate)
- History of abnormal mammogram findings
Gynecological Surgical History
- Previous gynecological surgeries (hysterectomy, myomectomy, oophorectomy, tubal ligation, D&C, laparoscopy)
- Dates and outcomes
- Current gynecological conditions (fibroids, endometriosis, PCOS, ovarian cysts)
Medical History and Medications
Full medication list including supplements, vitamins, and herbal remedies. Allergy list. Relevant medical conditions, paying particular attention to thyroid disorders, diabetes, hypertension, blood clotting disorders, and autoimmune conditions, all of which affect reproductive health.
Family History
Family history with reproductive health focus:
- Breast cancer (and age at diagnosis)
- Ovarian cancer
- Uterine cancer
- Endometriosis
- PCOS
- Blood clotting disorders
- Genetic conditions relevant to pregnancy
Insurance
Primary and secondary insurance, subscriber info, group and member ID numbers.
Consent
Consent for examination (including pelvic exam), consent for laboratory testing, HIPAA privacy notice, and e-signatures.
Building the Form
Generate the base structure with Formisoft's AI builder, then add the conditional sections: pregnancy history only for prior pregnancies, prenatal questions only for pregnancy visits, menopause screening only when age-appropriate. Patients complete it privately at home, not in a waiting room.
Attach it to your visit types and Formisoft shows who is ready before the appointment. See how patient readiness works.
Intake forms built for your specialty, ready before the visit.
- Forms, consents, and signatures before the visit
- Your paper forms converted by AI
- BAA included