About this template
Gathering detailed and accurate patient history is essential for providing exceptional women's health care. This OB-GYN Patient History Google Form template helps clinics, physicians, and health practices streamline their onboarding workflow by collecting crucial medical, surgical, and reproductive background information before a patient's appointment.
Designed with thoroughness and clarity in mind, the form captures vital data ranging from menstrual and pregnancy history to current medications, past gynecological conditions, and family medical history. By moving this intake process online, healthcare providers eliminate cumbersome paper clipboards, reduce administrative errors, and allow patients to complete their history comfortably from their own devices.
Doc2Form makes it easy to deploy, customize, and integrate this template directly into your practice's workflow. Ensure your care team has all the necessary clinical insights at their fingertips while delivering a seamless, digital-first experience for your patients.
Key features
- Collect comprehensive reproductive and menstrual history before appointments
- Streamline patient intake with structured medical and surgical background checks
- Gather family health history including genetic screening details
- Easily accessible on any device for convenient completion at home
- Securely organize and review responses directly in Google Sheets
Use cases
- New patient onboarding for obstetrics and gynecology practices
- Pre-appointment screening for annual wellness exams
- Specialized fertility and prenatal consultation intake
- Telehealth pre-visit health history assessments
What this form collects
- Full Name (Short answer)Enter your first and last name as it appears on your ID.
- Email Address (Short answer)Where we can reach you with appointment confirmations or follow-ups.
- Phone Number (Short answer)Include area code.
- Marital Status (Dropdown)Select your current marital status.
- Primary Reason for Visit (Paragraph)Briefly describe the main reason for your appointment today.
- Age at First Period (Short answer)Approximate age when you experienced your first menstrual cycle.
- Date of Last Menstrual Period (Date)Enter the first day of your most recent period.
- Period Regularity (Multiple choice)How regular are your menstrual cycles?
- Period Interval and Duration (Short answer)Average cycle length in days and bleeding duration.
- Pregnancy & Delivery History (Paragraph)Please detail total number of pregnancies, live births, miscarriages, or abortions if applicable.
- Current Birth Control Method (Checkboxes)Select all methods you currently use.
- Date of Last Pap Smear (Short answer)Approximate date or year of your most recent Pap smear.
- Date of Last Mammogram (Short answer)Approximate date or year of your most recent mammogram.
- Past Medical Conditions (Paragraph)List any chronic illnesses, major diagnoses, or hospitalizations.
- Current Medications (Paragraph)List all prescription medications, OTC drugs, vitamins, and supplements you currently take.
- Family Medical History (Paragraph)Note any history of cancer, heart disease, diabetes, or genetic disorders in close relatives.
- Patient Signature (Short answer)Please type your full legal name to confirm that the information provided is accurate to the best of your knowledge.
FAQ
How do patients access this form?
Once you convert or generate the Google Form using Doc2Form, you can share the link directly via email, text message, or embed it on your practice's website for patients to complete prior to their visit.
Can I customize the questions to fit my practice's needs?
Yes. Because it is a native Google Form, you have full freedom to add, remove, or edit any questions, sections, or response options to match your exact clinical requirements.
Where are the form submissions stored?
All patient responses are automatically saved in a secure Google Sheets spreadsheet linked to your Google Form, allowing your care team to easily review data before consultations.
Is this form mobile-friendly for patients?
Absolutely. Google Forms automatically optimizes layouts for smartphones, tablets, and desktop computers, ensuring a smooth experience for patients filling out their history on mobile devices.
How does Doc2Form help me set this up?
Doc2Form instantly transforms document templates into ready-to-use Google Forms, saving you hours of manual form building and formatting.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.