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Patient Intake Form

Dr. David Gerber
Gynecology
Labiaplasty
Aesthetics
Contact

Warning

Please book a consultation to view before and after photos.

Warning

Please book a consultation to view before and after photos.

Patient Intake

PATIENT INTAKE FORM

The information below will be used by Dr. Gerber and Meridia Medical staff to better serve you and make your visit more efficient. Any information submitted will remain confidential, will not be released and will only to be reviewed by Meridia Medical staff members.
This form is submitted using a SSL secure certificate

Disclaimer:* Any fields with the *(star) are required to make our intake process easier.
Personal Information
Name*
First Name Last Name
Age*
Birth Date*
Date Format: DD slash MM slash YYYY
Address*
Street Address Apartment/Suite # City State / Province / Region ZIP / Postal Code Country
Email*
Home Phone*
Work Phone
Mobile Phone*
Please check the telephone # we can use to contact you and to notify you of upcoming appointments:
The number that you prefer we call first
- Home
- Mobile
- Work
Health Card #
Health Card Expiry Date
Date Format: MM slash DD slash YYYY
Version Code: (The two letters following the ohip number)
Which province is your health card from?
Family Doctor
Referring Doctor’s name
Gynecological History
Age at your first period?
Are you menopausal? (No periods for one year or more)
- Yes
- No
Since when?
Date Format: MM slash DD slash YYYY
If Menopausal:
- Do you have hot flashes, insomnia, vaginal dryness etc?
- Are you using hormone replacement therapy?
- Have you had any vaginal bleeding/spotting/brown discharge?
First date of your last period
Date Format: DD slash MM slash YYYY
How often are your periods? (In days)
Are your periods regular?
- Yes
- No
How many days do you bleed?
Are your periods painful?
- Yes
- No
Are your periods heavy?
- Yes
- No
Do you bleed between periods?
- Yes
- No
Do you have bleeding after intercourse?
- Yes
- No
Date of your last PAP smear
Date Format: MM slash DD slash YYYY
Has your PAP smear ever been abnormal?
- Yes
- No
Have you had treatment for an abnormal PAP smear?
- Yes
- No
What form of contraception do you use now?
Have you ever used a birth control pill?
- Yes
- No
Have you ever used an IUD (Intra-Uterine Device)?
- Yes
- No
Have you ever had a Pelvic Infection (PID)?
- Yes
- No
Have you ever had any of the following infections?
Check all that apply
- Herpes
- Chlamydia
- Gonorrhea
- Warts
- Hepatitis B or C
- Syphilis
- None
Have you been tested for HIV(AIDS)?
- Yes
- No
Have you had a mammogram?
- Yes
- No
When last?
Date Format: MM slash DD slash YYYY
Have you had a bone density test?
- Yes
- No
When last?
Date Format: MM slash DD slash YYYY
Obstetric History
Have you ever been pregnant?
- Yes
- No
Please list ALL pregnancies (Date and outcome):
Date Outcome: (Miscarriage, Termination, Live Birth, Stillbirth etc Method: (D&C, Vaginal delivery, Forceps, C-Section) Sex Birthweight Comments
Medical History
Please list ANY medical conditions you have/had: (e.g. Asthma, Diabetes, Thyroid, Hypertension, Depression)
Type N/A if you’ve had none
Are you on any medications?
- Yes
- No
List ALL current medications:
Name and dose please, including Herbal and Natural remedies
Medication Name Dosage
Allergies to Medications:
If allergic, please list all drug names and the reaction.
Drug Name Reaction
Are you allergic to Latex?
- Yes
- No
Have you ever had a BLOOD Transfusion?
- Yes
- No
Have you ever had an operation?
- Yes
- No
What was the reason and date of your operation?
Name of operation Date
Have you EVER been hospitalized for any reason other than above?
- Yes
- No
Please state the reason and date of hospitalization
Reason Date
Do you smoke?
- Yes
- No
How many/day?
Do you drink alcohol regularly?
- Yes
- No
How many/day?
Family History: Any relatives with the following: (please indicate which relative.)
(Heart Disease, Diabetes, Hypertension Bleeding Disorders, Breast Cancer, Birth Defects, Ovarian Cancer, Blood clots, etc)
Condition/Illness Relative
Allergy: (please list all medications you are allergic to, as well as the type of allergy from the drop down list)
Others
Name of medications
Allergy or reaction to General anaesthetic or Local anaesthetic/freezing
- None
- React or allergy to local anaesthetic/freezing
- React or allergy to General Anaesthetic
Larger Genital Lips/Labia:
Many woman experience changes in the shape of the labia (genital lips). Sometimes these are longer, unusually shaped or one side is larger than the other. Often times the inner labia grow larger over time. Women may find that these changes affect them during exercise, during intercourse or when they wear tight clothing, requiring readjustment as they walk etc.

Some woman are just embarrassed about having larger labia and may avoid changing or showering at the gym in front of others or avoid intimacy and sexual relationships because of it. Often, there is a simple procedure that is commonly done at Meridia Medical to correct these changes.
If you are interested and wish to learn more about this, please do not be embarrassed and let us know by indicating yes or no
- Yes
- No
Sexual History
Many women have problems that interfere with intercourse and sexual satisfaction.Although it might be embarrassing at first, often these can easily be treated.

If you are comfortable answering these questions, we will try to help you.
Are you sexually active?
- Yes
- No
Do you have pain with intercourse?
- Yes
- No
Is the pain on the outside or deep inside?
- At the entrance
- Deep Inside
Do you have any problems with sexual relations?
Check any that apply or let us know of any additional problems.
- Lack of desire
- Low satisfaction
- Low lubrication
- Lack of enjoyment/orgasm
Additional problems:
Please comment below on any other problems with sexual relations so we can help.
Voiding and Prolapse History
Often women have problems with urine and bowel accidents. It is embarrassing and frustrating, and interferes with enjoyment of life.

Fortunately, these can be treated well in 85% of cases.
Do you have problems with passing/leaking urine?
It is normal to leak urine occasionally especially during exercise
- Yes
- No
Do you leak urine/have accidents?
- Yes
- No
Do you leak urine when coughing, laughing, sneezing, dancing, running etc? STRESS Incont:
- Yes
- No
Do you have to run to the toilet urgently when you feel the urge to go? URGENCY:
- Yes
- No
Do you sometimes leak before you reach the toilet bowl? URGE Incont:
- Yes
- No
Do you just leak at any time, without warning? UNAWARE Incont:
- Yes
- No
How often do you urinate during the day? FREQUENCY:
- Yes
- No
How many times do you wake up at night to urinate? NOCTURIA:
- Yes
- No
Do you ever find that your bed is wet from urine?
- Yes
- No
Do you completely empty your bladder each time?
- Yes
- No
Do you strain in order to urinate?
- Yes
- No
Do you wear pads/liners to protect you from urine leaking?
- Yes
- No
How many per day?
Are they soaked through?
- Yes
- No
Do you have accidents or staining on your underwear from Bowel Movements?
- Yes
- No
Do you have a pressure sensation/heaviness in you vagina area?
- Yes
- No
Have you noticed a bulge coming out from your vagina area?
- Yes
- No
Fluid Intake: How many cups per day:
Coffee
Tea
Water
Milk
Juice
Pop
Other Drinks:
Social History
Occupation
Relationship:
- Single
- Common-law
- Married
- Widow
- Other
Is your relationship with your husband/partner safe, and supportive?
- Yes
- No
Live alone?
- Yes
- No
Would you like to receive information on Meridia Medical events and blog tips?
- Yes
- No
CAPTCHA
When complete please submit.

For Labiaplasty please book a consultation at which time you can view before and after photos

(416) 484-8383

GYNECOLOGY

The Vagina and Vulva
The Vulva Area
What is the Vulva Area?
Vulva & Vaginal Care

GYNE TOPICS

Bartholins Cyst and Abscess
Colposcopy
Hysteroscopy
IUD Contraception
Leep Laser Care
Menopause & Sex
Vaginal Muscle Training & Sex
Vulvodynia-Vestibulodynia
Endometrial Currettage
Vaginal Discharge

LABIAPLASTY

Surgeon
Procedure

POST OP CARE

Hysteroscopic Care & Guidelines
Vulva Surgery Care
Leep – Laser – Cone Procedures Care
Care After A Miscarriage

Office Hours: Monday - Thursday 8-4 | Friday 8-12

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