Clearwater 727-796-7705 & Tampa 813-933-9166

Medical History Surgery Questionnaire

Please complete & submit this medical questionnaire in preparation for your surgery.

Your Personal Information

Chief Complaint

GYN History

Do you have pelvic pain? *
Do you have Dyspareunia (pain with intercourse)? *
Have you been diagnosed with Pelvic Inflammatory Disease? *
Do you have Dysmenorrhea (pelvic pain with menses)? *
Do you have a history of Fibroids? *
Do you have a history of Anemia? *
Have you ever had Chlamydia or Gonorrhea? *

OB History

Partner History

Patient History

Family History - Mother

Family History - Father

Family History - Siblings

Family History

(Includes: Mother, Father, In-laws, Grandparents, Aunts, Uncles, Siblings, etc.) Answer "None" if no family history.

Social History


By Submitting: I acknowledge that all information provided is accurate and true. I understand that providing incorrect information could affect my surgical outcome.
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