LOCAL INTAKE ASSESSMENT - Section 11 - Gynecology (Female Locals Only - leave blank and hit “submit” for male locals)

Local Full Name

First Name

Last Name

Gynecologist Name

First Name

Last Name

Gynecologist Phone Number

(###)

###

####

Gynecologist Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of last visit

YYYY

Reason

Number of Pregnancies

Is gynecology up to date?

Yes

Does the local need to be transferred to a new gynecologist through the wellness collective?

Birth control

Sexually Active

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