|
Age
|
LMP
|
|
Last pap smear
|
Last mammogram
|
|
Current BCM
|
Reason for visit
|
|
General WNL
|
Gen comments
|
|
Lungs WNL
|
Lungs comments
|
|
Cardiovascular WNL
|
Cardiovascular comments
|
|
Abdomen WNL
|
Abdomen comments
|
|
Breasts WNL
|
Breast comments
|
|
Neuro WNL
|
Neuro comments
|
|
Extremities WNL
|
Extremities comments
|
|
External Genitalia
|
External Genitalia Comments
|
|
Pelvic Exam Normal
|
|
|
Urethral Meatus WNL
|
Urethral Meatus
• • •
|
|
|
Urethral Meatus Comments
|
|
Bladder Normal
|
Bladder
• • •
|
|
|
Bladder Comments
|
|
Vagina Normal
|
Vagina
• • •
|
|
|
Vagina Comments
|
|
Cervix Normal
|
Cervix
• • •
|
|
|
Cervix Comments
|
|
Uterus Normal
|
Uterus
• • •
|
|
|
Uterus Comments
|
|
Adnexa Normal
|
Adnexa
• • •
|
|
|
Adnexa Comments
|
|
Anus/Perineum
|
Anus/Perieum
• • •
|
|
|
Anus/Perineum Comments
|
|
Rectal
|
Rectal
• • •
|
|
|
Rectal Comments
|
|
Stool guaic
• • •
|
|
|
ANNUAL
|
|
|
BIRTH CONTROL
• • •
|
BIRTH CONTROL
|
|
STD TESTING
• • •
|
STD Testing comments
|
