Locate us677 Cathedral Dr.
Rapid City, SD
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Main Clinic 605-343-9224
Appointments 605-342-6905

 
 

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 Black Hills OBGYN Patient Portal

 



 

Intake Form

To print and complete, click here to download.

 

Patient Last Name* First*
Email*
Allergies
Date of Birth* Age
Current medications (include doses)

OB/Gyn History

Pregnancy Summary:
Total Number of Pregnancies Number of Full Term Deliveries
Number of Preterm Deliveries Number of Miscarriages
Number of Abortions Number of Vaginal Deliveries
Number of C-Section deliveries Number of Children Living

Personal Gynecological History (mark all that apply):
 

 


 



 

Date of last menstrual period Are you menopausal?
Current method of birth control
 

Have you ever had your tubes tied?

 

Have you ever had a hysterectomy?

 

If yes, what kind?
Have you ever had a sexually transmitted disease?

 

If yes, mark all that apply



Date of last pap smear Results
Date of last mammogram Results

Have you ever had a colonoscopy?

 

If yes, when & result

Have you ever had a bone Deity screen?

 

If yes, when & result

Social History

Do you use alcohol?   Amount
Do you use tobacco?   Type/Amount
Do you have a previous history of smoking?   Quit Date
Do you use recreational drugs?  
History of Abuse    
Eating Disorder  
 
Living Situation    
   
 
Relationship Status
Are you currently sexually active  
Current Sexual Partner  
Have you ever been sexually active  
Current or most recent occupation:
Current employment status        

Personal Medical History (mark all that apply)





































Past Surgical History

Have you ever had a blood transfusion?  
If yes, have you ever had an adverse blood transfusion reaction?  
List any breast procedures you have had? (e.g. lumpectomy)
List any surgical procedures you have had:
Surgery Date Surgeon or Facility

Immediate Family History – specify relationship