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GYN History
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LMP
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Menstrual Problems
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Menstrual problem choices
• • •
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Comments
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Last Pap
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Abnormal Pap Smear of Cervix
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Abnormal Pap of Cervix Choices
• • •
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Comments
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Abnormal Pap Smear of Vagina
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Abnormal Pap of Vagina Choices
• • •
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Comments
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Method of Birth Control
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Birth Control Side Affect
• • •
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History of Infections
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HX of Infections Choices
• • •
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DES exposure
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New Field
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Endometriosis
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New Field
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Infertility
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Comments
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Previous Cancer
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Comments
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Abnormal Bleeding?
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Abn Bleeding Choices
• • •
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Comments
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Breast Problems?
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Breast Problem Choices
• • •
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Comments
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Medical History
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Past Med Hx 1
/
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Comments
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Past Med Hx 2
/
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Comments
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Past Med Hx 3
/
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Comments
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Surgeries
• • •
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Comments
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Childhood illnesses
• • •
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Comments
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Trauma
• • •
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Comments
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Personal Medical Conditions
• • •
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Comments
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Date of last PE
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PCP
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PCP Contact Info
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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
• • •
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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
• • •
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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
• • •
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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
• • •
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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 of Pregnancy/Labor
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Type of Delivery
• • •
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Sex
• • •
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Birth Weight In Pounds & Ounces
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Family History
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Father MH
• • •
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Comments
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Mother MH
• • •
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Comments
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Siblings MH
• • •
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Comments
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Grandparents MH
• • •
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Comments
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Children MH
• • •
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Comments
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Social History
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Marital Status
• • •
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Living Arrangements
• • •
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Comments
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Sexual Hx
• • •
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Comments
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Occupation
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Comments
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Caffeine
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Comments
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Tobacco
• • •
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Comments
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Alcohol
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Comments
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Potential Environmental Pathogen
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Patient's diet
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