Encounter date: ________________
Patient Initials: ______ Gender: Female__________ Transgender ____ Age: _________
Weight __________ Height _________ Pregnant: _________Gestational Age: __________
Last US Date: ________________
Chief Complaint:
HPI:
Menstrual history:
Age at menarche:
Last menstrual period: Menstrual pattern: Cycle length:
Duration of flow: Amount of flow: Bleeding pattern:
Associated pain (dysmenorrhea):
Break through bleeding:
Pre menopause/menopause: yes no
Vasomotor symptoms: yes no, if yes explain________________________________________
Hormone replacement therapy: yes no
Contraception: yes no Current method; satisfied with method? Yes no
Previous methods, including complications, reasons discontinued?
Cervical and vaginal cytology:
Most recent Pap smear result
History of abnormal Pap smears? If so, nature of diagnosis, treatment, and follow-up
History of sexually transmitted infections:
Vaginitis?
History of pelvic inflammatory disease?
Any difficulty conceiving in past? If so, prior evaluation and treatments
Sexually active:
History of sexual abuse or sexual assault?
Obstetric history:
G
T
P
A
L
Describe any maternal, fetal, or neonatal complications?
Allergies (Drug/Other):
PMH:
Current or past illnesses
Hospitalizations
Past surgical history
Current Meds:
Family Hx:
Immunization: Use attach table to document.
Social history: __ Married __Widowed __Single __ Divorced __Cohabitating Partner
Lives: ___ Home ___Alone ___ Family ___Caretaker __ ACLF ___ SNF ___
Other: Smoke ____ ETOH _________ Recreational Drug Use __________
Review of Systems:
General:
HEENT:
Eyes-
Ears-
Neck-
Nose-
Mouth-
Throat-
Lungs-
Cardiovascular-
Breast-
GI-
GU/Male/female genital-
Neuro-
Musculoskeletal-
Activity & Exercise-
Psychosocial-
Derm-
Nutrition-
Sleep/Rest-
Physical Exam
General:
HEENT: __________________________________________________________________________________________
Pulmonary: _________________________________________________________________________________________
Cardiovascular ______________________________________________________________________________________
Breast_____________________________________________________________________________________________
Abdomen __________________________________________________________________________________________
Rectal _____________________________________________________________________________________________
Male/female genital __________________________________________________________________________________
External genitalia:
Discharge:
Smell:
Pelvic pain:
Lesions, pruritus or burning:
Cervical motion:
Fundus height:
Musculoskeletal _____________________________________________________________________________________
Neuro _____________________________________________________________________________________________
Derm______________________________________________________________________________________________
Psych_____________________________________________________________________________________________
Misc ______________________________________________________________________________________________
Assessment
Significant Data/Contributing Dx/Labs/Misc
(Differential Diagnoses)
1.
2.
3.
4.
5.
6.
Plan (Consider: Diagnostic, Therapeutic, Educative, Referrals, & Follow-up)
1.
2.
3.
4,
5.
6.
Signature__________________________________________________________________________________________
Cite current evidenced based guideline(s) used to guide careMandatory)
1._____________________________________________________________________
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