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1. Patient Registration  |  2. Privacy Agreement Form  |  3. Credit Policy Form  |   4. OB/GYN History Form

Please take the time to complete our obstetrical / gynecological history form. This information will be used by our staff to familiarize our practice with your past medical history. This information will be made part of your permanent chart and will not be released to any other entity unless expressly requested by you. This form is secure and all information is encrypted to protect your personal information.

Please take the time to complete our obstetrical / gynecological history form. This information will be used by our staff to familiarize our practice with your past medical history. This information will be made part of your permanent chart and will not be released to any other entity unless expressly requested by you. This form is secure and all information is encrypted to protect your personal information.

PERSONAL INFORMATION

First Name*

Last Name*

Birth Date*

Today's Date*

MEDICAL HISTORY

Allergies (To Medications)*

Current Medications (Dose and Frequency)*

Primary Physician*

Past Medical Conditions*

Past Surgeries: (Dates and Reasons) *

Family History

Cancer*

Gynecological*

Problems / Surgery *

Breast Disease*

Past Surgeries:(Dates and Reasons)*

Do you use tobacco?*
Yes or No

If so how much

GYNECOLOGICAL HISTORY

Are you sexually active ?*
Yes or No

Contraception?*

List the age of your first period*

List your age at menopause*

Is your menstrual cycle regular?*
Yes or No

Do you have a heavy flow?*

When was your last menstrual period?*

Duration*

When did you have your last pap smear?*

Have you had an abnormal pap?*
Yes or No

If so any past treatment *

Have you had any breast problems or masses?*

Last Mammogram?*

Current and past gynecological problems (Please list all issues):

OBSTETRIC HISTORY:

Total number of pregnancies*

Total number of Vaginal Births*

Total number of Cesarean Section*

Total number of Ectopic/Tubal*

Total number of full term births*

Total number of Pre-term Births*

Total number of Abortions*

Total number of Miscarriages*

Convenient

Locations

Arboretum Office

3125 Springbank Ln.

Suite B

Charlotte, NC 28226

(704) 341-1103

Matthews Office

1450 Matthews Township Pkwy

Suite 310

Matthews, NC 28105

(704) 841-7225

Or email us at info@arboretumobgyn.com or call our office at 704-341-1103 and ask for access to the patient portal to electronically communicate with us!
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