Transcription of MRN: Patient Name - UCLA
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MRN: Patient Name - UCLA
Department of Obstetrics and Gynecology Patient history QUESTIONNAIRE UCLA Form #11864 Rev. (03/11) Page 1 of 4 MRN: Patient name : ( Patient Label) 16. OBSTETRICAL history INCLUDING ABORTIONS & ECTOPIC (TUBAL) PREGNANCIES CHILD Year Place of delivery or Abortion Duration Preg. Hrs. of Labor Type of Delivery Complications Mother and/or Infant Sex Birth Weight Present Health 18. Do you have a sexual partner? No Yes (Male Female ) 19. Are there concerns about your sexual activity which you may want to discuss with your doctor? Yes No A 1.
UCLA Form #11864 Rev. (03/11) Page 2 of 4 MRN: Patient Name: (Patient Label) G PAST SURGICAL HISTORY (Not OB/GYN) 21. List all surgeries and their year or None
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