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GYN HISTORY
JavaScript Form Validation
Question 1

What is your Email address?
Question 2

What is the name of the individual who needs doctor consultation?
Question 3

What is the date of birth of the individual who needs doctor consultation?
Question 4

Address

What is your mailing address?
Question 5

What was your mailing address from birth until now?
Question 6

Where is the patient now?
Question 7

Where do you live now?
How long have you lived at this address?
Question 8

How long do you plan to live at this address?
Question 9

What is your contact information including current mailing address, telephone, e-mail, and any other details, and person to contact in case of emergency?
Question 10

How old were you when you had your first period?
Question 11

Are your cycles regular/monthly?
Yes No
Question 12

How many days does your period last?
Question 13

If in menopause, at what age did it occur?
Question 14

Years of hormone replacement therapy?
Question 15

Are you currently sexually active?
Yes No
Question 16

If not, have you ever been sexually active?
Yes No
Question 17

Do you currently have a partner?
Yes No Partner’s gender
Question 18

How long have you been in this relationship?
Question 19

How many lifetime sexual partners have you had?
Question 20

At what age was your first intercourse?
Question 21

Have you ever been sexually abused, threatened or hurt by anyone?
Question 22

Are you experiencing any sexual problems?
Question 23

When was your last pap smear?
Question 24

Have you had any abnormal pap smears?
Yes No when?
Question 25

Have you been told you have HPV? Yes No when?
Question 26

Have you had any treatments for abnormal pap smears?
Yes No repeat pap colposcopy biopsy
Question 27

Have you received HPV vaccine?
Yes No date
Question 28

Have you ever had ovarian cysts?
Yes No
Question 29

Have you been told you have fibroids of the uterus?
Yes No
Question 30

Have you ever been treated for any sexually transmitted infections?
Yes No
Gonorrhea Chlamydia Syphilis Herpes Condyloma PID
Question 31

Current birth control
None Timing Condoms Diaphragm Birth control pills Patch Implants Depo Provera IUD Tubal ligation Vasectomy Ring Past birth control None Timing Condoms Diaphragm Birth control pills Patch Implants Depo Provera IUD Tubal ligation Vasectomy Ring
Question 32

Have you ever had a yeast infection?
Yes No Chronic? Yes No
Question 33

Have you ever been treated for a vaginal bacterial infection (bacterial vaginosis)?
Yes No Chronic? Yes No
Question 34

Do you ever have problems with urinating such as infections, frequency, loss of urine, blood in your urine?
Yes No
If yes, please
explain__________________________________________________________________________________
Question 35

When was your last mammogram?
Question 36

Have you had any abnormal mammograms?

Yes No
Question 37

Have you had any breast biopsies?

Yes No If yes, result
Question 38

Do you do breast self examination?

Question 19

Have you ever had a sexually-transmitted disease?
Question 20

Would you use a condom when having sex with a partner you ---------?
I have read and agree to the Terms & Conditions.

What is Gynecology?
Gynecology is the branch of medicine that deals with diseases and disorders of the female reproductive system. Most gynecologists are obstetricians as well, but the specialty of obstetrics is limited to the care of pregnant women and the delivery of infants.

The organs and structures studied by the gynecologist are the ovaries, oviducts, uterus, cervix, vagina, vulva, and breasts. Among the various diseases and disorders that affect these structures are congenital defects, infections, inflammations, benign and malignant tumors, disturbances of the sex hormones, and injuries, particularly those that occur during childbirth.

In addition to these disorders, the gynecologist is concerned with functional (nonpathological) disturbances of the reproductive system, including sterility and certain menstrual disorders. He may also instruct his patients on the proper use of contraceptives and prescribe contraceptive drugs or devices.