Gynecology Annual Examination Form


Gynecology Annual Examination Form (Maureen Padden, MD and Alan Lim, MD) © 2007, Family Practice Notebook, LLC http://www.fpnotebook.com/GYN203.htm

HEALTH RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE
___/___/___ Time:  ________ Asst.:  ________ Provider: _________ Age: ____ yo LMP: ___/___/__ BP:  _____/____ HR: _______ Temp: ____.___ RR:  _______ HT:  ______ WT: _____lb/kg TOB:    No / Yes       ___________ ETOH:  No / Yes        ___________ ALLERGIES:   (  ) NKDA        ___________        ___________ MEDICATIONS  WELL WOMAN EXAM  -  Family Practice Clinic
PATIENT PLEASE ANSWER THE FOLLOWING QUESTIONS:
 Date of last pap smear?  ____ / ____ / ____                            Results (circle one):  Normal   Other(___________)
 Date of last mammogram (if applicable)?  ____ / ____ / ____     Results (circle one):  Normal   Other(___________)
 Pregnancy History:         Total #:  _____      Deliveries:  _____      Miscarriages:  _____      Abortions:  _____
                                         Living children:  ____     Date of last Delivery? ____ / ____ / ____ (Vaginal or C-section)
 Current contraception (circle any)? Vasectomy in partner Depo-provera Diaphragm Natural planning
Tubal ligation Birth control pills IUD Other: ____________
Abstinence Norplant Condoms     None
Please circle  “Yes”  or  “No”  to the following questions:
Do you have a history of abnormal paps? No Yes    Date/treatment:  _______________
Have you had treatment for an abnormal pap? No Yes    Explain:  ____________________
Do you need a refill of contraception? No Yes
Are you sexually active? No Yes
Have you ever had a “sexually transmitted disease”? No Yes    Date/treatment:  _______________
Are you possibly pregnant? No Yes
Noticed any vaginal discharge or abnormal bleeding? No Yes
Do you have a family history of breast cancer? No Yes    Who, at what age?  ____________
Do you have a personal history of breast cancer? No Yes    Date/treatment:  _______________
Do you do self breast exams? Yes No
Noticed any concerning breast lumps? No Yes
Any history of physical or sexual abuse? No Yes
Do you have an Advance Directive (ie. Living Will)? Yes No
What medical problems do you have (circle all that apply)? What surgeries have you had (circle all that apply)?
DES exposure Hypertension Tuberculosis Appendectomy Ovary Other:  _________
Diabetes Liver disease Thromboembolism C-section
Gallbladder Migraines Other:  __________ Gallbladder _______________
Heart disease Stroke _________________ Hysterectomy
 Which of the following runs in your family medical history (circle all that apply)?
Diabetes High blood pressure Colon,  Ovary or Uterus Cancer Tuberculosis
Heart disease Stroke Other cancers:  ______________ Other:  _______________
                                                                  
 What “alternative” medical therapies are you using (circle all that apply)?
Acupuncture Chiropractic Healing touch Herbs Massage Therapy Other:  ____________
PATIENT’S IDENTIFICATION (Use the Imprint Card) RECORDS MAINTAINED AT:
PATIENT’S NAME (Last, First, Middle initial) SEX FEMALE
RELATIONSHIP TO SPONSOR STATUS RANK/GRADE
SPONSOR’S NAME ORGANIZATION
DEPART./SERVICE SSN/IDENTIFICATION NO. DATE OF BIRTH
                                                                                   Well Woman PAP,  FPC          01/12/ 00
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
___/____/___ S:
O:     NL General Exam ABNL Comments
HEENT

                                                                       

                                                                                                                                                                                                                         
Thyroid
Breasts
Heart
Lungs
Abdomen
Lymphadenopathy
Skin
NL Pelvic Exam ABNL
NS: KOH: Guiac: Neg / Pos Vulva
Vagina
Cervix
Uterus
Adnexa
Rectovaginal
A:
See Summary
of Care Sheet.
See Medication Flow Sheet, Immunization Record. P: (  )  Pap (  )  Mammogram (  )  Radiology studies:  Dexascan _______________
(  )  HCG (  )  Consults: ______ (  )  GC, Chlamydia / HBsAg / HIV, HSV, RPR, VDRL
(  )  UA / C&S (  )  EKG:  _________ (  )  Serum labs: CBC   Chem-7   FSH   FOBT   Lipid
                           LFT   TSH        _________________
(  )  Prescription / Medication changes:             (  )  DepoProvera 150mg, IM, q 3 months x 4     BCP _____________     Diaphragm _____                        IUD ________________     Condom     Other _________________             (  )  Premarin 0.625mg qd / Provera 2.5mg qd / PremPro qd     Calcium 500mg BID
Counseling on: (  )  Advance Directives (  )  Medication (  )  Tobacco cessation encouraged
(  )  Contraception / STD (  )  HRT/Calcium (  )  Handouts given:  __________
(  )  Diet / Exercise (  )  SBE (  )  Other:  __________________
(  )  Follow-up in  ____  weeks  ____  months  ____  year  or as Pap Smear results indicate.
                   
______________________________________
     Provider’s Signature  and   Stamp
Well Woman PAP,  FPC                   BACK


2007-07-10

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