Women's Health Annual Exam Form

Women's Health Annual Exam Form — Form Fields

This healthcare template includes 8 fields. Pre-visit questionnaire for women's health annual exams covering reproductive history, menstrual health, screening history, and preventive care. Supports thorough gynecological assessments. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Date of last menstrual period (multiple choice, optional) — options: Within the past month, 1–3 months ago, More than 3 months ago, Post-menopausal, Currently pregnant
• Date of last Pap smear / cervical screening (multiple choice, optional) — options: Within the past year, 1–3 years ago, More than 3 years ago, Never
• Date of last mammogram (if applicable) (multiple choice, optional) — options: Within the past year, 1–2 years ago, More than 2 years ago, Not applicable
• Menstrual or Hormonal Symptoms (select all that apply) (checkboxes, optional) — options: Irregular periods, Heavy bleeding, Severe cramps, Hot flashes or night sweats, Mood changes
• Are you currently using any form of contraception? (multiple choice, optional) — options: Yes, No, Prefer not to say
• Health Questions or Concerns for Today (long text, optional)