Gynae history template PDF

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Gynae history template...

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GYNAECOLOGICAL HISTORY PRESENTING COMPLAINT

HISTORY OF PRESENTING COMPLAINT 

Abdominal or pelvic pain (SOCRATES)

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Vaginal bleeding – o Establish the pattern, amount and any associated symptoms o Post coital o Inter-menstrual bleeding o Post-menopausal bleeding

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Vaginal discharge o Volume o Colour o Consistency o Smell

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Dyspareunia o Pain during sexual intercourse o Location of pain – superficial or deep o Duration o Nature

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Vulval skin changes and itching

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Vaginal lumps

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Infertility o How long have you been trying to fall pregnant o Any investigations relating to fertility o Assisted conception previously o Previously pregnant

GYNAECOLOGICAL HISTORY ASSOCIATED SYMPTOMS      

Urinary symptoms Bowel symptoms Fever Malaise Unintentional weight loss Abdominal distension

MENSTRUAL HISTORY   

Age at menarche Duration Frequency

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Menstrual blood flow – assessment of the volume of menstrual bleeding, changes to blood flow, passing any clots

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Dysmenorrhoea (SOCRATES)and any changes to pain during recent periods

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Date of LMP Contraceptives Menopause

SEXUAL HISTORY   

One regular sexual partner? How long have you been together? Type of sex with sexual contact

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Screening for STIs Treated for any STIs or chlamydia

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Contraception

GYNAECOLOGICAL HISTORY PAST GYNAE HISTORY 

Cervical screening o Date of last cervical screening test o Result of last screen o Receiving any treatment if cervical screening test was abnormal

     

Ectopic pregnancy STIs Endometriosis Bartholin’s cyst Cervical ectropion Malignancy

PAST MEDICAL HISTORY    

Migraines Previous VTEs Breast cancer Blood disorders

PAST SURGICAL HISTORY     

Abdominal or pelvic surgery Caesarean section LETZ Vaginal prolapse repair Hysterectomy

DRUG HISTORY DRUG

INDICATION

GYNAECOLOGICAL HISTORY FAMILY HISTORY   

Ovarian, endometrial and breast cancer Bleeding disorders VTE

SOCIAL HISTORY    

Occupation Smoke Drink Hobbies

(risk assessment)...