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Encounter date: ________________
Patient Initials: ______ Gender: Female__________ Transgender ____ Age: _________
Weight __________ Height _________ Pregnant: _________Gestational Age: __________
Last US Date: ________________
Age at menarche:
Last menstrual period: Menstrual pattern: Cycle length:
Duration of flow: Amount of flow: Bleeding pattern:
Associated pain (dysmenorrhea):
Break through bleeding:
Pre menopause/menopause: yes no
Vasomotor symptoms: yes no, if yes explain________________________________________
Hormone replacement therapy: yes no
Contraception: yes no Current method; satisfied with method? Yes no
Previous methods, including complications, reasons discontinued?
Cervical and vaginal cytology:
Most recent Pap smear result
History of abnormal Pap smears? If so, nature of diagnosis, treatment, and follow-up
History of sexually transmitted infections:
History of pelvic inflammatory disease?
Any difficulty conceiving in past? If so, prior evaluation and treatments
History of sexual abuse or sexual assault?
Describe any maternal, fetal, or neonatal complications?
Current or past illnesses
Past surgical history
Immunization: Use attach table to document.
Social history: __ Married __Widowed __Single __ Divorced __Cohabitating Partner
Lives: ___ Home ___Alone ___ Family ___Caretaker __ ACLF ___ SNF ___
Other: Smoke ____ ETOH _________ Recreational Drug Use __________
Review of Systems:
Activity #038; Exercise-
Male/female genital __________________________________________________________________________________
Lesions, pruritus or burning:
Significant Data/Contributing Dx/Labs/Misc
Plan (Consider: Diagnostic, Therapeutic, Educative, Referrals, #038; Follow-up)
Cite current evidenced based guideline(s) used to guide careMandatory)
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