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GYN History
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Date of last Menses
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Menstrual problem choices
• • •
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Menstrual Problems Freewrite
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Last Pap Taken
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Previous Abnormal Paps?
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Pap (When and How Abnormal) Free
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Abnormal Pap of Cervix Choices
• • •
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Method of Birth Control
• • •
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Birth Control Problems
• • •
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Method of Birth Control Freewite
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Contraceptive Information?
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Infection HX of Uterus, Ovaries,
• • •
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History of Infections Freewrite
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DES Exposure?
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Endometriosis?
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Endometriosis When and Tx
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Infertility (time, tests, tx?)
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Breast Problem Choices
• • •
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Previous Cancer?
• • •
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Abnormal Bleeding?
• • •
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Abnormal Bleeding Freewrite
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Breast Problems?
• • •
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Breast Problems Freewrite
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Obstetric History
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Year
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Length of Pregnancy?
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Hours in Labor?
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Complications of Pregnancy/Labor
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Type of Delivery
• • •
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Sex M/F
• • •
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Birth Weight In Pounds & Ounces
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Year
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Length of Pregnancy?
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|
Hours in Labor?
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Complications in Pregnancy/Labor
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Type of Delivery
• • •
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Sex M/F
• • •
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|
Birth Weight In Pounds & Ounces
|
|
|
Year:
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Length of Pregnancy?
|
|
Hours in Labor?
|
Complications in Pregnancy/Labor
|
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Type of Delivery
• • •
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Sex M/F
• • •
|
|
Birth Weight In Pounds & Ounces
|
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|
Year
|
Length Of Pregnancy?
|
|
Hours in Labor
|
Complications in Pregnancy/Labor
|
|
Type of Delivery
• • •
|
Sex M/F
• • •
|
|
Birth Weight In Pounds & Ounces
|
|
|
Year
|
Length of Pregnancy?
|
|
Hours in Labor
|
Complications of Pregnancy/Labor
|
|
Type of Delivery
• • •
|
Sex M/F
• • •
|
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Birth Weight In Pounds & Ounces
|
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Medical History
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Heart Disease
|
Heart Disease Freewrite
|
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Heart Murmur
|
Heart Murmur Freewrite
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Rheumatic Fever
|
Rheumatic Fever Freewrite
|
|
Mitral Valve Prolapse
|
Mitral Valve Prolapse Freewrite
|
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Irregular Heart Beat
|
Irregular Heart Beat Freewrite
|
|
High Blood Pressure
|
High Blood Pressure Freewrite
|
|
Varicose Veins
|
Varicose Veins Freewrite
|
|
Thrombophlebitis
|
Thrombophlebitis Freewrite
|
|
Ulcers
|
Ulcers Freewrite
|
|
Hepatitis
|
Hepatitis Freewrite
|
|
Colitis
|
Colitis Freewrite
|
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Gallbladder Disease
|
Gallbladder Disease Freewrite
|
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Diarrhea/Constipation
|
Diarrhea/Constipation Freewrite
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Rectal Bleeding
|
Rectal Bleeding Freewrite
|
|
Hemorrhoids
|
Hemorrhoids Freewrite
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Seizures/Epilepsy
|
Seizures/Epilepsy Freewrite
|
|
Migraines
|
Migraines Freewrite
|
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Asthma
|
Asthma Freewrite
|
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Pneumonia
|
Pneumonia Freewrite
|
|
Bronchitis
|
Bronchitis
|
|
Tuberculosis
|
Tuberculosis Freewrite
|
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Bladder/Kidney Infections
|
Bladder/Kidney Infections Freewr
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|
Blood in Urine
|
Blood in Urine Freewrite
|
|
Urine Loss with Cough/Sneeze
|
Urine Loss with Cough/Sneeze Fre
|
|
Anemia
|
Anemia Freewrite
|
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Bleeding Problems
|
Bleeding Problems Freewrite
|
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Previous Transfusions
|
Previous Transfusions Freewrite
|
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Diabetes
|
Diabetes
|
|
Thyroid Disease
|
Thyroid Disease Freewrite
|
|
Arthritis
|
Arthritis Freewrite
|
|
Mononucleosis
|
Mononucleosis Freewrite
|
|
Rubella (German Measles)
|
Rubella (German Measles)
|
|
Stroke
|
Stroke Freewrite
|
|
Paralysis
|
Paralysis
|
|
Tobacco Use
|
|
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Tobacco
• • •
|
Age Began Smoking
|
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ETOH Use
|
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Alcohol
|
Age Began Drinking
|
|
Caffeine Use
|
|
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Caffeine
|
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Other Medical HX
|
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Medical Allergies
|
Reaction to Medical Allergies
|
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Present Medications
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Surgical History
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Year
|
City/State
/
|
|
Type of Surgery
|
Surgeries Not Listed
|
|
Surgical Complications
|
|
|
Year
|
City/State
/
|
|
Type of Surgery
|
Surgeries Not Listed
|
|
Surgical Complications
|
|
|
Year:
|
City/State
/
|
|
Type of Surgery
|
Surgeries Not Listed
|
|
Surgical Complications
|
|
|
Year
|
City/State
/
|
|
Type of Surgery
|
Surgeries Not Listed
|
|
Surgical Complications
|
|
|
Year
|
City/State
/
|
|
Type of Surgery
|
Surgeries Not Listed
|
|
Surgical Complications
|
|
|
|
|
|
Family History
|
|
|
Father MH
• • •
|
Comments
|
|
Mother MH
• • •
|
Comments
|
|
Siblings MH
• • •
|
Comments
|
|
Grandparents MH
• • •
|
Comments
|
|
Children MH
• • •
|
Comments
|
|
|
|
|
Anything Medical Not Covered Abo
|
|
