Greater Houston OB/GYN – Memorial Hermann Tower

(713) 935-9791

929 Gessner Road, Suite 2150, Houston, TX 77024

Patient Portal

  • Home
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    • Our Practice
    • Policies
    • Financial Policies
  • Our Doctors
    • Carol Michele Storey, M.D.
    • Sharon S. MCCloskey, M.D.
    • Camille V. Boon, M.D.
    • Ashley Hester, MD
    • Anne V. Gonzalez, M.D.
  • Services
  • Resources
    • Patient Forms
    • Website Links and Booklets
  • Contact Us
  • Home
  • About
    • Our Practice
    • Policies
    • Financial Policies
  • Our Doctors
    • Carol Michele Storey, M.D.
    • Sharon S. MCCloskey, M.D.
    • Camille V. Boon, M.D.
    • Ashley Hester, MD
    • Anne V. Gonzalez, M.D.
  • Services
  • Resources
    • Patient Forms
    • Website Links and Booklets
  • Contact Us

Medical History

Marital Status(Required)
Medical History(Required)
Have you ever had any of the following?
List all medications & dose you are currently taking, including over-the-counter medications, vitamins and herbal remedies:
Allergies(Required)
List any Allergies to Medication
List any Reactions to Medication

Surgical History

Obstetrical History

I have...(Required)

Pregnancy History

Please list all pregnancies in order, including miscarriages, premature births, stillbirths, ectopics (tubal) and abortions:
Add Pregnancy? (2)
Add Pregnancy? (3)
Add Pregnancy? (4)
Add Pregnancy? (5)

Gyn History

Lasting:(Required)
Periods are:(Required)
Flow is:(Required)
If it applies
If it applies
Are you sexually active?(Required)
Recent New Partners?(Required)
Sexual Preference(Required)
Birth Control Method(Required)
Have you ever had any of the following STD's?(Required)
Have you ever received Gardasil (HPV) Vaccine?(Required)
Received All 3 Doses?(Required)
Have you ever had any of the following?(Required)
Was Pap smear(Required)
Have you ever needed any of the following for an abnormal pap?(Required)
Mammogram was:(Required)
Bone density was:(Required)
Colonoscopy was:(Required)

Family History

Please list any close relatives with history of the following: Please list Relationship/Age at Diagnosis/Status
Heart attack, stroke, bypass surgery.

Social History

Alcohol Use(Required)
Tobacco Use(Required)
Street drug use(Required)
Excercise(Required)
Caffeine(Required)
Coffee, tea, soda.
Sexual Abuse(Required)
If yes, are you safe now?(Required)
Have you received counseling?(Required)
Physical Abuse(Required)
If yes, are you safe now?(Required)
Have you received counseling?(Required)
Emotional Abuse(Required)
If yes, are you safe now?(Required)
Have you received counseling?(Required)

Quick Contact

Office : 713-935-9791
Fax : 713-467-9709
Email :[email protected]

Office Hours

Monday–Thursday:
8:00am - 5:00pm

Friday:
8:00am - 12:00pm

Quick Links

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Location

929 Gessner Road, Suite 2150
Houston, TX 77024

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