The OB-GYN Patient History Form is a specialty intake questionnaire that collects a woman's menstrual, obstetric, gynecologic, and sexual health history along with her general medical background. OB/GYN practices use it before a new-patient visit or annual exam so the clinician can review reproductive risk factors ahead of time. This template is a starting point; confirm wording with your own clinical and compliance team.
What does an OB-GYN Patient History Form include?
Content mirrors the obstetric and gynecologic history clinicians take at an initial visit. Most forms gather the following sections:
- Menstrual history. Age at first period, cycle length and regularity, date of last menstrual period, and any bleeding or pain concerns.
- Obstetric history. Number of pregnancies, births, and outcomes (gravida and para), along with delivery methods and any complications.
- Gynecologic history. Dates and results of prior Pap tests, HPV testing, mammograms, and any history of abnormal results or procedures.
- Contraception and sexual health. Current birth control method, sexual activity, and history of sexually transmitted infections.
- Medical and surgical history. Chronic conditions, prior surgeries, hospitalizations, and any pelvic or breast procedures.
- Medications and allergies. Current prescriptions, over-the-counter drugs, supplements, and documented drug allergies with reactions.
- Family history. Relatives with breast, ovarian, uterine, or colon cancer and other hereditary conditions that affect screening.
- Social history. Tobacco, alcohol, and substance use, plus lifestyle factors relevant to reproductive and preventive care.
How to administer the OB-GYN Patient History Form
- Send the form by text or email when the appointment is booked so the patient can complete it at home.
- Let the patient fill in menstrual, obstetric, and gynecologic details privately, at her own pace.
- Have staff review the responses for gaps or flags before the visit begins.
- Collect an electronic signature and date if your practice attests to history at intake.
- Store the completed form securely so the care team can view it before the patient is roomed.
- Resend the form to returning patients each year to confirm cycle changes, new pregnancies, and updated medications.
Who uses the OB-GYN Patient History Form?
- OB/GYN physicians and nurse practitioners reviewing reproductive risk before an exam.
- Certified nurse midwives establishing obstetric history at a first prenatal visit.
- Women's health and family medicine clinics offering annual well-woman exams and screening.
- Front-desk and medical assistant staff preparing charts and flagging items for the clinician.
Digital vs paper OB-GYN Patient History Form
| Paper | Zentake digital |
|---|---|
| Handwriting can be hard to read | Typed, legible responses every time |
| Filled in a rushed waiting room | Completed at home before the visit |
| Ink signature on paper | Secure electronic signature |
| Stored in a physical file | Encrypted HIPAA-compliant storage |
| Re-filled from scratch each year | Prior answers updated in minutes |
| Staff scan and file by hand | Ready for the team automatically |
How Zentake helps with the OB-GYN Patient History Form
- Custom form builder. Build the history questionnaire to match your menstrual, obstetric, and gynecologic sections.
- Before the visit. Forms reach patients ahead of time so OB/GYN practices start each appointment with history in hand.
- E-signatures. Capture a signed attestation that the history is complete and accurate.
- In-clinic tablets. Hand a tablet to patients who did not finish the form at home.
- HIPAA compliant. Every response is encrypted, and a signed BAA is included on every plan.
References
The standard sections above follow the obstetric and gynecologic history described in the Merck Manual Professional Edition, which outlines menstrual, obstetric, gynecologic, and sexual history taking. The American College of Obstetricians and Gynecologists (ACOG) publishes well-woman visit recommendations that inform screening-related fields.
This template is a general starting point and not legal or clinical advice. Confirm required fields and any attestation language with your practice's clinical leadership and compliance counsel, since requirements vary by state and setting.
Last updated: August 2026