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Age
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Reason for visit
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LMP
|
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Last pap smear
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Last mammogram
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Current Birth Control
• • •
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No. of years on OCP
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History of abnormal pap smear
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Abnormal pap follow up
• • •
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Age First Menses
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Age of Menopause
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Age of first intercourse
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Any sexual partners with history of IV drug use
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Personal history STDs
• • •
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Comments
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Birth history
/
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Comments birth history
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Family cancer history
• • •
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Comments family cancer history
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Gyn symptoms
• • •
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Additional Complaints
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General WNL
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Gen comments
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Lungs WNL
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Lungs comments
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Cardiovascular WNL
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Cardiovascular comments
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Abdomen WNL
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Abdomen comments
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Breasts WNL
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Breast comments
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Neuro WNL
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Neuro comments
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Extremities WNL
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Extremities comments
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External Genitalia
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External Genitalia Comments
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Pelvic Exam Normal
|
|
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Urethral Meatus WNL
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Urethral Meatus
• • •
|
|
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Urethral Meatus Comments
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Bladder Normal
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Bladder
• • •
|
|
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Bladder Comments
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Vagina Normal
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Vagina Comments
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Vagina
• • •
|
|
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Cervix Normal
|
Cervix
• • •
|
|
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Cervix Comments
|
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Uterus Normal
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Uterus
• • •
|
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Uterus Comments
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Adnexa Normal
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Adnexa
• • •
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Adnexa Comments
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Anus/Perineum
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Anus/Perieum
• • •
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Anus/Perineum Comments
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Rectal
|
Rectal
• • •
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Rectal Comments
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Stool guaic
• • •
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ANNUAL
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BIRTH CONTROL
• • •
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BIRTH CONTROL
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STD TESTING
• • •
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STD Testing comments
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