Initial GYN visit form

THIS RECORD IS CONFIDENTIAL
INITIAL GYN MEDICAL RECORD
PLEASE LEAVE BLANK ANY ITEM OF WHICH YOU ARE UNSURE AND PRINT YOUR RESPONSES.
Today’s Date: ________________
Name: ________________________________________________Student ID # ______________________________
Date of Birth: _________________ Age: ______ Gender: _________________Expected Graduation Date__________
If you live on campus: Housing Building/Room #________________________________________________________
Home Address: ____________________________________City/State:________________________Zip:___________
REASON FOR TODAY’S VISIT: __________________________________________________________________
CONTACT INFORMATION
What is the best way to contact you:
[ ] Call phone # _______________________________________
[ ] Other (email)_______________________________________
When we contact you with results, we will ask you a security question to verify your identity over the telephone. Please
select a question and answer (that you will remember) that only you would know the answer to.
My question:____________________________________________ My Answer:____________________________
YOUR HEALTH/ WELLNESS/ LIFESTYLE
Do you consider yourself to be in good health? [ ] Yes [ ] No
If no, explain:___________________________________________________________________________
Have you received the Gardasil (Human Papilloma Virus) Vaccine? [ ] No [ ] Yes
If yes, when______________________________________________
Do you or have you ever smoked cigarettes/cigars? [ ] No [ ] Yes If yes, amount/day_____________________
Do you or have you ever consumed alcohol? [ ] No [ ] Yes
If yes, amount/day___________ or amount/week________________
What street drugs have you used?_____________________ How often___________ Date last used______________
Have you ever used IV drugs? [ ] No [ ] Yes
Have you ever had sex with an IV drug user?
[ ] No [ ] Yes [ ] Unknown
Name and location of your gynecologist____________________________________________________________
Do you perform self -breast exams monthly?
[ ] No [ ] Yes

SEXUAL HISTORY
Have you ever had sexual intercourse? [ ] No [ ] Yes
Age at first intercourse_______
Have you had more than one sex partner in the past 12 months? [ ] No [ ] Yes
Number of sex partners in the past 3 months: ______
Number of partners in your lifetime___________
Sites of sexual contact: [ ] oral [ ] vaginal [ ] anal Partners have been: [ ] Male [ ] Female [ ] Both
Has your partner ever had sex with the same gender?
[ ] No [ ] Yes [ ] Unknown
Have any of your partners ever been treated for a sexually transmitted disease? [ ] No [ ] Yes [ ] Unknown
Do you know the HIV status of your partner?
[ ] Negative [ ] Positive [ ] Unknown
Have you ever been physically or sexually abused or raped? [ ] No [ ] Yes If yes, was it reported? [ ] Yes [ ] No
If yes, when: ________________________ Did you receive counseling? [ ] Yes [ ] No
Do you use condoms? [ ] Always [ ] Sometimes [ ] Never
Have you ever been exposed to / treated for a sexually transmitted disease? [ ] No [ ] Yes
HAVE YOU EVER HAD?
DATE TREATED DATE TREATED
HPV/ GENITAL WARTS Y / N MOLLOSCUM Y / N
CHLAMYDIA Y / N HERPES TYPE________ Y / N
GONORRHEA Y / N SYPHILIS Y / N
VAGINAL INFECTIONS
(YEAST, BV, CERVICITIS)
Y / N
PELVIC INFLAMMATORY
DISEASE
Y / N
TRICHOMONIASIS Y / N SCABIES OR CRABS Y / N
MENSTRUAL HISTORY
When was the first day of your last period? _________________________ Was this a normal period? [ ] Yes [ ] No
How often do you get a period? _____________ How many days do your periods last? _____________
Age at onset of first period ________________ Since your last period, have you had unprotected sex? [ ] Yes [ ] No
When was your last Pap? ______________ Have you ever had an abnormal Pap? [ ] No [ ] Yes
If yes, describe. _________________________________________________
What kind of birth control do you use? _________________________ Are you satisfied with your method? [ ] Yes [ ] No
Has there been a change in your menstrual periods? [ ] No [ ] Yes Do you experience pain or bleeding
Do you have any bleeding between periods? [ ] No [ ] Yes with intercourse? [ ] No [ ] Yes
Do you have a history of vaginal discharge? [ ] No [ ] Yes Have you ever been pregnant? [ ] No [ ] Yes
Do you get severe cramps or PMS? [ ] No [ ] Yes If yes, how many times? _____________
Have you noticed and breast lumps/ tenderness? [ ] No [ ] Yes What was the outcome? (e.g. birth,
miscarriage, abortion)
Do you have any nipple discharge?
[ ] No [ ] Yes

ALLERGIES (Please list all allergies)
Medication
Foods
Latex
Environmental
*If you have no allergies, check here: [ ]
REACTION
MEDICATIONS (Include all prescription, over-the-counter, herbal, and vitamins)
NAME OF MEDICINE DOSE LAST TAKEN
*If you do not take any medications, check here: [ ]
MEDICAL HISTORY
General:
Please list any medical conditions you have:______________________________________________________________________
Hospitalizations/Surgeries/Injuries:_____________________________________________________________________________
Do you have or have you ever had: (Circle Y for Yes and N for No).
Neurological: Gastrointestinal: Nutritional:
Y / N Frequent, severe headaches or Migraines Y / N Abdominal Pain/ Pressure Y / N Weight Loss/ Gain More
Y / N Vision Problems Y / N Stomach/ Intestine Problems Than 10 Pounds
Y / N Seizures, Fainting Y / N Liver/ Gallbladder Disease Y / N Obesity
Y / N Stroke Genitourinary: Y / N Eating disorders
Y / N Mood Disorders Y / N Bladder/ Kidney Problems Immunologic:
Cardio-Respiratory: Y / N Pain, Burning, Frequent Urination Y / N HIV/ AIDS
Y / N High Blood Pressure Y / N Incontinence Y / N Cancer
Y / N Heart Problems, Murmurs Musculoskeletal/Rheumatic: Hematologic:
Y / N Chest Pain Y / N Lupus (SLE) Y / N Sickle Cell Disease/Trait
Y / N Rheumatic Fever Y / N Osteoporosis Y / N Thyroid Disease
Y / N Blood Clots, Varicose Veins, Leg Pain Y / N Arthritis Y / N Diabetes
Y / N High Cholesterol
Y / N Blood Disorder
Y / N Difficulty Breathing
Y / N Chronic Cough/Asthma/TB
To the best of my knowledge, the above information is completed and accurate:
PATIENT SIGNATURE _____________________________________________________________ DATE:__________________
OFFICE VISIT POLICY: Any students who are late to their appointment by 10 MINUTES or more will be rescheduled. Students
are advised to call Health Services at least 24 HOURS before the scheduled appointment if they need to cancel. Missed appointments
are subject to a $15 fee. Health Services will call or email students two business days before their scheduled appointment. This call
should be returned or email replied to by the student by the end of that day in order to confirm the appointment. If the student does not
confirm the appointment, Health Services will cancel it and you will need to reschedule. Please sign and date below that you have read
and understand our office visit policy.
PATIENT SIGNATURE: ___________________________________________________________ DATE: _________________

Health Services (office use only)
Student Name:________________________ID#_________________
HISTORY OF CHIEF COMPLAINT: __________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Vital Signs Tests Results Control Reference Labs Check Wet Mount
Ht_____
Wt_____ Pregnancy Test [ ] Pos [ ] Neg
Line
Y / N
Range
Negative Thin Prep PAP
If Done
[ ] Hyphae
T _______ Hgb Value
M:13-18g/dL HPV
[ ] Trich
HR_______
N/A F:11-16g/dL Chlamydia
[ ] Clue Cells
BP_________
HIV# [ ]Pos [ ] Neg Y / N Negative GC [ ] Whiff
WNL N/A Describe variance Herpes [ ] WBCs
Thyroid VDRL/RPR [ ] Lactobacilli
Heart Oral Swab [ ] pH______
Lungs
Rectal Swab
Abdomen
Urinalysis
Perineum
Urine C&S
Lymph
Breasts
Vagina
Cervix
Uterus AV RV MID
Adnexa
Penis
Testicles
Scrotum
Rectum
Prostate Boggy Firm Nodule
Dorsal Ventral Rectum
Anterior Posterior
R Breast Exam L
Cervix
ASSESSMENT/ PLAN
Diagnosis:______________________________________ [ ] initial/ annual/ GYN exam [ ] birth control refill
[ ] STI screening
[ ] Rx given:_____________________________________ Notes/Follow up:
[ ] Side effects discussed
[ ] ACHES reviewed
Health Maintenance:
[ ] STI information
[ ] Condoms encouraged [ ] given
[ ] SBE taught/encouraged
[ ] STE taught/encouraged
[ ] Smoking Cessation
[ ] Other___________________
_______________________________________
Practitioner Signature
__________________
Date