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Female History
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Pregnancy History
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Age at 1st pregnancy
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G (Number of Pregnancies)
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P (Number of Pre-term Pregnancies)
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T (Number of Full Term Pregnancies)
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A (Number of Abortions/Miscarriages)
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L (Number of Living Children)
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Gynecological History
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Current Menstrual Status
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Current menstrual status freewrite
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Post-menopausal
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Was your menopause
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Menopause freewrite
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Age at first menstrual period
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Age at last menstrual period
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LMP
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Nature of cycles
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Nature of cycles freewrite
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Average length of menstrual flow
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Length of cycle
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Gynecological medical History
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Gynecological medical history freewrite
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Family Planning History
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Current birth control method
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Past Birth Control Methods Used
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Are you currently sexually active?
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Health Maintenance
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Pap smear?
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Pap?
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Date of last pap smear
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Result of last pap smear
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History of abnormal pap smears?
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Abnormal pap?
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Date(s) of abnormal pap
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Result of abnormal pap smear
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Mammogram?
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Mammogram?
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Date of last mammogram
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Result of last mammogram
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Patient's Care Team
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PCP
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PCP Contact Information
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Ob/Gyn
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Ob/Gyn Contact Information
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