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Ob Gyn Patient History Form Template

Streamline Patient Information Collection with This Template

Gathering comprehensive health information can be a daunting task for any OB/GYN. This OB/GYN Patient History Form Template is designed to simplify that process, helping you efficiently compile critical data from your patients about their health and pregnancy history. You'll benefit from time savings, improved patient communication, and the ability to provide tailored care-all while ensuring your forms comply with WCAG standards for accessibility. Experience how easy it is to customize and integrate this template into your practice's workflow.

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Full name
Date of birth
Sex assigned at birth
Female
Male
Intersex
Prefer not to say
Email address
Mobile phone number
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Emergency contact full name
Emergency contact phone number
Insurance provider
Member or policy ID
Reason for today's visit
Annual well-person exam
Pregnancy care
Contraception
Fertility concerns
Menstrual concerns
Pelvic pain
Urinary or vaginal symptoms
Follow-up
Other
Please Specify:
Current symptoms (select all that apply)
Please Specify:
Are you currently pregnant?
Yes
No
Unsure
Date of last menstrual period (LMP)
Current birth control method(s)
Please Specify:
Number of pregnancies (Gravida)
Number of births (Para)
Past pregnancy complications
None
Gestational diabetes
High blood pressure or preeclampsia
Preterm labor or birth
Cesarean delivery
Postpartum depression
Heavy bleeding/hemorrhage
Blood clots
Other
Please Specify:
Planning pregnancy in the next 12 months?
Yes
No
Unsure
Menstrual pattern
Regular
Irregular
Absent
Perimenopausal
Postmenopausal
Not applicable
Menstrual symptoms (select all that apply)
None
Severe cramps
Heavy bleeding
Clots
Bleeding between periods
Severe PMS or PMDD
Severe pain (dysmenorrhea)
Other
Please Specify:
History of gynecologic conditions (select all that apply)
None
Endometriosis
Polycystic ovary syndrome (PCOS)
Uterine fibroids
Ovarian cysts
Pelvic inflammatory disease (PID)
Abnormal Pap or HPV
Infertility
Other
Please Specify:
Date of last Pap or HPV test
Result of last Pap or HPV test
Normal
Abnormal
Unsure
Not applicable
Are you currently sexually active?
Yes
No
Prefer not to say
Would you like STI screening today?
Yes
No
Unsure
History of sexually transmitted infections (select all that apply)
Please Specify:
Ongoing medical conditions (select all that apply)
Please Specify:
Allergies (include medications, foods, or latex)
Current medications and supplements
Tobacco or nicotine use
Never
Former
Current daily
Current occasional
Vaping only
Prefer not to say
Alcohol use
None
Occasional
Weekly
Daily
Prefer not to say
Family history (blood relatives) of the following
Please Specify:
HPV (human papillomavirus) vaccination status
Completed series
Started but not completed
Not vaccinated
Unsure
Preferred contact method
Phone call
Text message
Email
Patient portal
No preference
Signature
Date signed
Consent to evaluation and treatment by the OB GYN team
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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paper art illustration depicting an ob gyn patient history form for article on form creation using FormCreatorAI

When to use this form

Use this form before a first prenatal visit, an annual well-woman exam, preconception counseling, or when a patient reports abnormal bleeding, pelvic pain, or possible pregnancy. It gives you a clear picture of cycles, obstetric history, symptoms, and risk factors so you can triage and plan care fast. Pair it with the Patient information form to pre-fill demographics and contacts, and the Doctor information form to coordinate referring or primary care providers. Clinics can also send it ahead of telehealth visits to reduce charting time and guide labs or imaging on day one. The result: fewer follow-up calls, safer prescriptions, and a more personalized plan.

Must Ask Ob Gyn Patient History Questions

  1. What is the date of your last menstrual period (LMP), and are your cycles regular?

    LMP pinpoints pregnancy dating and helps assess irregular bleeding, perimenopause, or contraception needs. Cycle regularity guides timing for labs, ultrasounds, and fertility counseling.

  2. How many pregnancies have you had (including miscarriages and abortions), and what were the outcomes or complications?

    A detailed obstetric history flags risks for the current visit or pregnancy. It helps you prepare counseling, prophylaxis, and appropriate monitoring.

  3. What gynecologic symptoms are you experiencing now (pain, abnormal bleeding, discharge, itching, or urinary issues)?

    Specific symptoms and duration drive triage, from urgent evaluation of ectopic warning signs to routine workups. Clarity reduces follow-up messages and ensures you order the right tests first.

  4. What contraception or hormones do you use, and when was your last Pap or HPV test?

    Knowing method and hormone use prevents interactions and supports safe prescribing. Last screening date and results keep you on the right Pap/HPV schedule; for a complete medication list and allergies, capture details in the Medical information form.

  5. Do you have a personal or family history of breast, ovarian, uterine, or colon cancer?

    These histories can change screening, genetic counseling, and imaging decisions. If more detail is needed, have patients complete the Family medical history form.

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