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Gynological and Obstetrical History
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Gynological Comment:
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Vulva/Vagina: (No discharge/itching/lesions/lumps)
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Last Pap Smear
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Pap Findings
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History of Abnormal Pap
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Do you have a uterus?
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Do you have both ovaries?
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Do you have a cervix?
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Menstruation
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Current Menstrual Status
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Menopause
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Age at first menstrual period:
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Date of Last Period
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Are periods (or were periods) usually regular?
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Frequency of menstruation:
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Length of average period
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Painful periods?
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If periods are painful, how painful?
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Spotting or bleeding between periods?
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Recent change in frequency of periods?
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Recent change in duration of bleed?
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Have periods recently become very heavy?
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Issues with periods:
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Problems with PMS/PMDD?
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Menstruation Comment:
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Obstetrics
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Method of Birth Control
• • •
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Number of pregnancies:
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Number of children:
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Number Adopted:
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Age when first child was born:
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Age when last child was born:
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Number of full term births:
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Number of premature births:
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Number of miscarriages:
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Number of abortions:
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Number of living children:
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Complications during pregnancy, delivery, or postpartum:
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Obstetrical Comment:
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Midlife Symptoms
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Hot flashes:
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Night sweats:
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Difficulty with sleep:
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Heart palpitations or a sensation of butterflies in chest or stomach:
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Skin is crawling or itching:
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More tired than usual:
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Difficulty concentrating:
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Issues with memory:
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More irritable than usual:
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More anxious than usual:
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Increase is depressed moods:
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Mood Swings:
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Tearfulness:
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Headaches:
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Urinary frequency:
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Leaking urine:
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Pain or burning with urination:
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UTI
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Uncontrollable loss of gas or stool:
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Vagninal Dryness:
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Abnormal vaginal discharge:
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Vaginal infections:
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Pain during sex:
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Pain inside during intercourse:
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Bleeding after intercourse:
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Lack of desire or interest in sexual activity:
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Difficulty achieving orgasm:
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Stomach feels bloated or gained weight:
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Symptoms comment:
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