OB/GYN · Medical history

OB-GYN Patient History Form

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

PaperZentake digital
Handwriting can be hard to readTyped, legible responses every time
Filled in a rushed waiting roomCompleted at home before the visit
Ink signature on paperSecure electronic signature
Stored in a physical fileEncrypted HIPAA-compliant storage
Re-filled from scratch each yearPrior answers updated in minutes
Staff scan and file by handReady 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

Frequently asked

OB-GYN Patient History Form questions, answered.

What does an OB-GYN Patient History Form include?

It collects a patient's menstrual history, obstetric history such as pregnancies and births, gynecologic history including Pap and mammogram results, contraception and sexual health, plus medical, surgical, family, and social history. Together these sections give the clinician a full reproductive and preventive-care picture before the exam begins.

Who fills out the form?

The patient completes it, usually at home before a new-patient visit or annual well-woman exam. Zentake sends the form by text or email when the appointment is booked. Staff then review the answers for gaps or flags, and the clinician confirms key details during the visit itself.

When should the form be updated?

Resend it to returning patients at least once a year. Cycles change, new pregnancies occur, screening results come in, and medications are added or stopped. In Zentake a returning patient can update prior answers in minutes instead of completing a blank form from scratch every visit.

Is the OB-GYN Patient History Form a legal requirement?

No single federal rule mandates its exact contents. Practices design the form around clinical standards from bodies like ACOG and their own protocols. Because documentation and consent rules vary by state and setting, confirm your fields and any signature requirements with your compliance or legal team.

Is the form HIPAA compliant in Zentake?

Yes. Responses are encrypted in transit and at rest, access is limited to your team, and Zentake includes a signed business associate agreement on every plan. Patients complete the form on their own device or an in-clinic tablet, and the record stays in Zentake ready before the visit.

Can we customize the sections?

Yes. The form builder lets you add, remove, or reword fields so the menstrual, obstetric, gynecologic, and social sections match how your practice takes history. You can also make items required, add screening questions, and adjust language for prenatal, annual, or problem visits.

In Zentake

Send the OB-GYN Patient History Form in three clicks.

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