|
Age:
|
Pain (0-10 Scale)
|
|
LMP
|
G:____
|
|
P:____
|
A:____
|
|
Hysterectomy
|
___ Year if yes
|
|
Last PAP date
|
|
|
Review of PMH
|
Changes
|
|
Review of FMH
|
Changes
|
|
Sexually Active
|
|
|
Number of Partners
|
Male/Female/Both
|
|
Smoker
|
Drug Use
|
|
Review of Systems
|
|
|
HEENT Normal
|
HEENT Normal
• • •
|
|
Description of Abnormal
|
|
|
Genitourinary
|
Genitourinary
• • •
|
|
Description of Abnormal
|
|
|
Gastrointestinal
|
Gastrointestinal
• • •
|
|
Description of Abnormal
|
|
|
Cardiovascular
|
Cardiovascular
• • •
|
|
Description of Abnormal
|
|
|
Musculoskeletal
|
Musculoskeletal
• • •
|
|
Description of Abnormal
|
|
|
Breasts
|
Breasts
• • •
|
|
Description of Abnormal
|
|
|
Pulmonary - Normal
|
Description of Abnormal
|
|
Neurological
|
Neurological
• • •
|
|
Neurological
|
|
|
Psycological
|
Psycological
• • •
|
|
Description of Abnormal
|
|
|
Cervix - Normal
|
Description of Abnormal
|
|
Genitalia (ext)
|
Genitalia (ext)
• • •
|
|
Description of Abnormal
|
|
|
Uterus - Normal
|
Description of Abnormal
|
|
Vagina - Normal
|
Description of Abnormal
|
|
Rectum
• • •
|
Description of Abnormal
|
|
STD (GC/Chlamydia/Trich):
|
Yeast/BV
|
|
PAP
|
HPV
|
|
Hemacult
|
Results
|
|
Mammogram
|
Results
|
|
Colonoscopy
|
Results
|
|
EKG
|
Results
|
|
CXR
|
Results
|
|
Bone Density
|
Results
|
|
Labs
|
|
|
Other Screening
• • •
|
Other
|
|
Patient Education
• • •
|
|
|
Diagnosis
|
Plan
|
