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Patient Information
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G
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P
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LMP
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Last Pap Smear
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UCG../ Pregnant
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New Yes / No
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Previous Biopsy
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Previous Therapy
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Ultrasound
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New Yes / No
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Hyperplasia
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New Yes / No
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Dysplasia
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New Yes / No
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Abnormal bleeding
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New Yes / No
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Condyloma
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New Yes / No
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Pelvic Exam Normal
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Pelvic Diagram
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Pelvic Exam Comments
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Colopscopy Diagram
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Colpo Comments
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Endometrial BX
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Comment
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Cryo-Therphy
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Comment
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External Genitalia
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External Genitalia
• • •
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External Genitalia Comments
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Urethral Meatus
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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
• • •
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Vagina Comments
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Cervix Normal
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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
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Rectal
• • •
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Rectal Comments
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