Gynecological History FormToday’s date: Year 20

MonthDay

Name: ______________________________________
Age: ________ years old

1. When was the first day of yourlast menstrual period?

Start day: Month
Duration:days

Day□Unknown□ I am pregnant

2. When was the first day of yourperiod before the one above?

Start day: Month
Duration:daysDay□Unknown□ I am breastfeeding□ Age at menopause: ________(including positive pregnancy test)

What would you like to discuss with your doctor today?
Please place a ✔ in the appropriate □ and give us details in the column on the right.
□ Pregnancy□ Menstrual period(Please be specific)

Please pick up an “Obstetrical History Form” at the front desk.
□Menstrual pain
□Heavy bleeding □Bleeding with clots □Premenstrual syndrome
Pain relief medicine: ()I am taking
Kampo (traditional herbal medicine): ()medications
Other: ()□ Abnormal vaginal bleeding□ Abnormal vaginal discharge□ Abdominal / lower back pain

□Before my period □Several days after my period □Other□Heavy □Odor/smell □Change in color: ()□During my period □Before my period □Not related to my period□During sexual intercourse □During bowel movements□During urination □Comes and goes (Please explain below):()□ Abnormalities of the vulva/vagina□Itching□ Fertility treatment□ Menopause

Did not use birth control for:Please explain:□ Contraceptives (Birth control)□ Emergency contraception(date & time of sexual intercourse: MonthDay□ Birth control pills □ IUD (Intrauterine Device)
I want to avoid having my period:From MonthDay～ To Month□ Delaying/preventing
menstrual periods□Gynecological examination / check□Sexually Transmitted Diseases(STD) test
□Abnormalities found at another
health facility or during healthcheck-ups□Pain□Sores/bumps□Discomfortyears and□Cervical cancer (entrance to the uterus)□Uterine cancer (inside the uterus)□Chlamydia □Syphilis □Gonorrhea □HIV
□Other: (monthsTime)Day□Hepatitis B)

Please explain:
Name of the health facility: ()□OtherAiiku Clinic International Unit
Revised 2017/10/20 PC desktop

Name:Height: ________cm⚫

*If you are pregnant, write your usual weight

Menstrual Period

Menstrual cycle

Weight: ________kg

Cycle length: ~days (first day of your period to the first day of your next period)
Duration of bleeding:daysInterval: □Regular □Irregular
Menstrual flow / bleeding: □Light □Moderate □Heavy
Symptoms: □Abdominal pain □Headache □Lower back pain

Age at first period

years old

Age at menopause

years old

Pregnancy History⚫

Past pregnancies: _____times ・ Delivery: ______times ・ Miscarriages: ______times
Abortions: _______times ・ Other: ________________________________________________________#Delivery Date
Year/Month/DayYourage1_____ /___ /___g2_____ /___ /___g

Weeks

Birth
Weight3_____ /___ /___g

4_____ /___ /___g

5_____ /___ /___g

Baby ishealthy

Type of Delivery

□M

□Yes

□Vaginal □Cesarean

□F

□No

□Vacuum/Forceps

□M

□Yes

□Vaginal □Cesarean□F□No□Vacuum/Forceps

□M

□Yes

□Vaginal □Cesarean□F□No□Vacuum/Forceps

□M

□Yes

□Vaginal □Cesarean□F□No□Vacuum/Forceps

□M

□Yes

□Vaginal □Cesarean□F□No□Vacuum/Forceps

Any pregnancy-related complications in the past:□High blood pressure □HELLP Syndrome □Seizures □Massive bleeding□Gestational Diabetes □Other:_____________________⚫

Miscarriage
Abortion
Ectopic

Sex

Place ofDelivery□Placenta abnormalities

Gynecological and Medical History□Uterine fibroids □Endometriosis □Adenomyosis□Sexually transmitted disease (STD) □Other:□Abnormal uterus shape□Ovarian tumor□Hypertension (high blood pressure) □Diabetes □Kidney disease □Heart disease □Thyroid disease□Hepatitis (liver inflammation) □Autoimmune disease □Asthma (write date of last episode below)□Cancer □Stroke □Cerebral hemorrhage (bleeding in the brain) □Seizures □Mental/psychiatric illness□Glaucoma □Blood disease □Thrombosis (blood clot) □Other:
Please give details about the items you checked✔ above.
□Hospitalization□Surgery□Blood transfusion

⚫

Other

□Alcohol (times / week)□Current medications:⚫

Family History□Smoking (cigarettes / day)

*Please write relationship to you in the ( ). Example: ☑Cancer (grandfather-stomach, father-lung)□High blood pressure ()□Venous thromboembolism (blood clot in the vein) (□Blood disease (such as hemophilia) (□Other hereditary diseases (□Diabetes ()))

□Cancer ())

Physician’s signature:
Aiiku Clinic International Unit
Revised 2017/10/20 PC desktop