6400 Brooktree Court, Suite 100, Wexford PA 15090  Phone: 724-933-3310  Contact Us

Patient Registration

Gynecology Patients

All required information is marked with *.

Identifying Information

* Date of Birth:

Husband/Partner's Date of Birth:

Specific Problems

What is/are your problems? Check all that apply:

Menstrual History

Date of your last period:

Are your periods regular?

Do you have:

Do you have pain/cramps with your periods?

Is the pain severe?

Do you take medication for the pain?

Do you have swelling/bloating before your periods?

Do you usually get depressed, irritable, or unusually hungry before your periods?

Obstetrical History

Live Births





Gynecological History

Have you ever had an abnormal Pap smear?

Have you ever had and/or been treated for excessive hair on your face or body?

Have you ever been treated for acne?

Do you have milky discharge from your nipples?

Have you ever had an infection of your tubes?

Have you ever had a venereal disease? (gonorrhea, chlamydia, herpes, condyloma/warts)

Do you have frequent vaginal infections?

Are you using a form of birth control now?

Contraceptive History
Oral Contraceptives (pill)




Medical History

Have you lost or gained greater than 15 lbs during the past year?

Do you follow a particular food diet or have any special dietary habits?

Do you take over-the-counter medication frequently?

Are you allergic to x-ray dye or iodine?

Are you allergic to latex?

Do you smoke cigarettes?

Do you drink alcohol?

If yes:

Do you use illicit/recreational drugs?

Medical History

Please check all of the following that apply to you:

Surgical History

Past abdominal surgery (check all that apply) and fill in Month/Year:

Have you ever had a conization, cautery, freezing, or laser therapy of your cervix?

Family History

Do any of your living or deceased relatives have cancer of the breast, uterus, ovary, or cervix?

Is there a history of fertility problems in any of your direct relatives?

Is there a history of hormonal disorders, diseases known to be passed genetically, or birth defects in your family?

Does any member of your immediate family have a history of thyroid disease?

Did your mother or any sisters have a hysterectomy?

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