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NAME OF PARTNER(optional)
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PARTNER'S DATE OF BIRTH
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REFERRED BY
• • •
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ADDRESS OF PHYSICIAN/CLINIC
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PHONE NUMBER OF PHYSICIAN/CLINIC
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NEW/RETURNING PATIENT
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REASON FOR TODAY'S VISIT
• • •
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REASON FOR TODAY'S VISIT IN DETAIL
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IMPORTANT INFORMATION ABOUT TODAY'S VISIT
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CYCLE HISTORY
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AGE OF FIRST MENSTRUAL PERIOD
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DATE OF MOST RECENT MENSTRUAL PERIOD
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CYCLE INTERVAL
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DAYS BETWEEN CYCLES
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DATE OF LAST 3 PERIODS (Month and Date)
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DAYS OF MENSTRUAL FLOW
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MENSTRUAL DISCOMFORT
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LOCATION OF MENSTRUAL DISCOMFORT
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SPOTTING OR BLEEDING
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COMMENTS (completed by physician)
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PAP SMEAR HISTORY
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DATE OF LAST PAP SMEAR
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RESULTS OF LAST PAP
• • •
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LAST PAP DONE BY
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ADDRESS/PHONE OF PHYSICIAN/CLINIC
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HISTORY OF ABNORMAL PAP
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HISTORY OF HPV
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DATE(S) OF ABNORMAL PAP
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PROCEDURES FOR ABNORMAL PAP:
• • •
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FAMILY HISTORY CANCER OF UTERUS CERVIX OVARIES
• • •
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HAD GARDASIL (HPV) VACCINE AS A CHILD
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COMMENTS (completed by physician)
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BREAST CONCERNS
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DO YOU CHECK YOUR BREAST REGULARLY?
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BREAST COMPLAINTS
• • •
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DATE OF LAST BREAST SONOGRAM
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RESULTS OF LAST BREAST SONOGRAM
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DATE OF LAST MAMMOGRAM
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RESULT OF LAST MAMMOGRAM
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ABNORMAL BREAST SONO/MAMMO/MRI
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HISTORY OF BREAST BIOPSY/IMPLANTS/REDUCTION
• • •
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FAMILY HISTORY OF BREAST CANCER
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WHICH FAMILY MEMBER/S
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COMMENTS
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GYN HISTORY AND CONCERNS:
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DATE OF LAST VAGINAL SONOGRAM
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RESULTS OF LAST SONOGRAM
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DATE OF LAST PELVIC MRI (UTERUS/OVARIES)
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RESULTS OF PELVIC MRI
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GYN INFECTIONS
• • •
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HISTORY OF VAGINAL DISCHARGE
• • •
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PAST/CURRENT COMPLAINTS OF UTI
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EXPLAIN
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HISTORY OF ENDOMETRIOSIS
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EXPLAIN
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HISTORY OF FIBROIDS
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EXPLAIN
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PCOS AND INSULIN RESISTANCE
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SIGNS OF POLYCYSTIC OVARIAN SYNDROME
• • •
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COMMENTS
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BIRTH CONTROL HISTORY
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BIRTH CONTROL USED IN THE PAST
• • •
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BIRTH CONTROL USED CURRENTLY
• • •
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PREGNANCY HISTORY
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NUMBER OF PREGNANCY
• • •
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1ST PREGNANCY DATE
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1ST PREGNANCY COMMENTS
• • •
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2ND PREGNANCY DATE
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2ND PREGNANCY COMMENTS
• • •
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3RD PREGNANCY DATE
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3RD PREGNANCY COMMENTS
• • •
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4TH PREGNANCY DATE
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4TH PREGNANCY COMMENTS
• • •
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5TH PREGNANCY DATE
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5TH PREGNANCY COMMENTS
• • •
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6TH PREGNANCY DATE
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6TH PREGNANCY COMMENTS
• • •
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7TH PREGNANCY DATE
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7TH PREGNANCY COMMENTS
• • •
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PERSONAL HEALTH HISTORY
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MEDICAL HISTORY
• • •
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OTHER, DESCRIBE IN COMMENTS
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ALLERGIES
• • •
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COMMENTS
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MEDICATION ALLERGIES
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COMMENTS
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FAMILY HISTORY
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FAMILY HISTORY
• • •
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RELATION - DISEASE
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SURGICAL HISTORY
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HISTORY OF ANY SURGERIES
• • •
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DATES/REASONS FOR SURGERY
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IMMUNIZATION HISTORY
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VACCINES
• • •
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GARDASIL VACCINE
• • •
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COVID HISTORY
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HAD COVID INFECTION
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HAD COVID VACCINE
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DOSES OF COVID VACCINE
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BRAND OF COVID VACCINE
• • •
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HAD BOOSTER SHOTS
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SOCIAL HISTORY
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MARITAL STATUS
• • •
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OCCUPATION
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LIFESTYLE
• • •
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POTENTIAL EXPOSURES
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FERTILITY HISTORY
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PARTNER'S NAME
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PARTNER'S DOB
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COUPLE HAS BEEN TOGETHER SINCE
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COUPLE TRYING TO CONCEIVE SINCE (No birth control)
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PARTNER'S MEDICAL HISTORY
• • •
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PARTNER'S SURGICAL HISTORY
• • •
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PARTNER'S MEDICATIONS
• • •
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PARTNER'S UROLOGIC PROBLEMS
• • •
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PARTNER'S FAMILY HISTORY
• • •
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GENETIC DISORDERS IN PARTNER'S FAMILY
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NUMBER OF CHILDREN FROM PREVIOUS PARTNERS (AGE)
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SPERM ANALYSIS IN PAST
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DATE & RESULTS OF SPERM TEST/S
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COMMENTS ABOUT PAST SPERM TEST/S
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FERTILITY TESTS COMPLETED SO FAR
• • •
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FERTILITY TREATMENTS DONE SO FAR
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SKIN
• • •
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SKIN NORMAL
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NEUROLOGIC
• • •
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NEUROLOGIC
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EYES
• • •
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EYES
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EAR NOSE THROAT MOUTH
• • •
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EARS NOSE MOUTH THROAT NL
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CARDIOVASCULAR
• • •
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CARDIOVASCULAR NL
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RESPIRATORY
• • •
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RESPIRATORY NL
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GASTROINTESTINAL
• • •
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GASTROINTESTINAL NL
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GENITOURINARY
• • •
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GENITOURINARY NL
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MUSCULOSKELETAL
• • •
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MUSCULOSKELETAL NL
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HEMATOLOGIC/ LYMPHATIC
• • •
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HEMATOLOGIC/LYMPHATIC NL
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PSYCHIATRIC
• • •
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PSYCHIATRIC NL
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PHYSICAL EXAM
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HEIGHT AND WEIGHT/BMI
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CONSTITUTIONAL - Appears well-developed and well-nourished. Well-oriented to time, place, person
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BREAST EXAM - Breasts symmetric size. No mass palpated. Nipples normal w/o discharge.
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EXTERNAL GENITALIA - Pubic hair normally distributed. External genitalia unremarkable. Glands appear normal.
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URETHRA - Meatus appears normal.
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VAGINAL EXAM - Vaginal mucosa appears normal.
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CERVICAL EXAM - Cervix appears normal. No discharge. No lesions. No polyp. Pap smear and cultures performed.
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UTERUS - Feels normal-size, mobile.
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ADNEXA - Normal to palpation. No mass appreciated.
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PERINEUM - Unremarkable. No perianal abnormalities appreciated.
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ABDOMEN - Soft, non-tender
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DIAGNOSTICS
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PAPSMEAR ANL
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PAPSMEAR NL
|
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PELVIC ULTRASOUND ANL
|
PELVIC ULTRASOUND NL
|
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PAP SMEAR / CULTURES
|
IUD REMOVAL
|
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ASSESSMENT
|
IMPRESSION CHOICES
• • •
|
|
PLAN
|
PLAN SELECTION
• • •
|
