Download GYN visit worksheet

Signature OB/GYN
A Community Specialty Practice of Johns Hopkins Medicine
New Patient Worksheet for GYN exam
Name:
Date:
1. The reason for your upcoming visit: ___ Well Woman Visit
___ Problem Visit
___ Pre or Post-Op Visit
___ Procedure
___Post Partum
___ Other
2. Are there GYN problems that need attention? ___ yes ___ no
If yes explain.
THERE MAY BE A SEPARATE CHARGE ADDED FOR A PROBLEM.
3. Check if one of the following applies to you:
____ I have started/completed the Gardasil (HPV) vaccine series (women age 26 years or less)
____ I am menopausal (no period for 1 year or more).
____ I have had a hysterectomy or an endometrium ablation.
____ I am on birth control that suppresses my period.
4. Are you sexually active?
___never
___ yes
___ no
5. Do you have sex with:
___ men
___ women ___ both
6. Would you like to have a HIV test?
___ yes
___ no
7. Would you like STI testing?
(Sexually transmitted infection)
___ yes
___ no
8. Do you need contraception?
___ yes
___ no
9. Who is your primary care physician?
* IF YOU ARE HERE FOR A PROBLEM VISIT, PLEASE COMPLETE BOTH SIDES OF FORM.
DO NOT WRITE BELOW IN THIS BOX. FOR OFFICE USE ONLY.
LMP: ____________________________
Age:
Last Pap:
BP:
/
Last Mammogram:
Physician’s Signature:
Weight:
Height:
Parity:
U/A:
Allergies:
Date:
Last revision: 02/18/2015
Welcome to Signature OB/GYN
PLEASE COMPLETE THIS SIDE, IF YOU ARE HERE FOR A PRE-OP OR PROBLEM VISIT
Name:
If you were referred by another physician, please indicate their name:
Please circle only those conditions that are current or ongoing problems:
FOR BOTH PROBLEM VISITS AND PRE-OP VISITS:
Fever
Headaches, Dizziness, Lightheadedness
Sinus congestion
Irregular Heartbeat, Chest Pain
Cough, Shortness of Breath
Nausea, Vomiting, Diarrhea, Constipation
Urinary frequency, urgency, burning
Unexplained easy bleeding, easy bruising, History of blood transfusion
Anxiety, Depression, Psychiatric admission
Skin rash, Piercings (other than ears)
No symptoms or problems. Review of systems is negative.
PRE-OP PATIENTS ONLY:
Sleep apnea
Problems with anesthesia excluding vomiting
Recent Dental problems
Recent use of ANY of the following medications:
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Weight loss products
Blood thinners, such as Warfarin, Plavix, or Pradaxa
St.John’s Wort
Phentermine
Ibuprofen, Aleve, or similar medications
Aspirin
Ma Haung
Tenuate
 Lithium
Last revision: 02/18/2015