GYN FORM
The College Of WILLIAMSMARY Student HealthCenter
GYN Page
Date of Exam
Month Day Year
Date
Name
ID#
Birth date
Month Day Year
Date
Address
Phone
Age
FAMILYHISTORY - Has anyone in your immediate family had trouble with the following? Include mother (M), father (F), brother (B), sister (S), aunt (A), grandmother (GM
Clotting disorder Breast disease Breast cancer in female relative
GYN cancer High blood pressure Stroke Blood clots
age 50 in immediate family Osteoporosis
MEDICAL HISTORY - Information about you YesNow No
Headaches/frequent Migraine headaches Severe depression Severe mood changes Cancer Eating disorder Diabetes
Thyroid problem Breast disease High blood pressure Shortness of breath Heart disease/problem Blood clots Liver disease
Urinary tract infections in last year Smoking # of cigarettes /wk how long? Alcohol use # drinks/day # drinks/wk Recreational drug use Regular exercise
GYN HISTORY
Pelvic infections (PID) Pelvic surgery Abnormal pap report Positive HPV test
Sexually transmitted infections (STIs) type Vaginal infections type
Pregnancy/abortion Gardasil vaccine
First day of last menstrual period
# periods/year
Any problems with your periods?
Last pap smear date
Month Day Year
Date
result
Have you ever been sexually active? If yes, date of first intercourse or genital contact Do you / have you had sex with Have you ever been in a relationship where you have been threatened or harmed in any way? Condom/dental dam protectionAlwaysSometimesNever Have you or any of your partners been at increased risk for HIV infection (multiple partners bisexual experience, used IV drugs, multiple STIs)? NoYes
No Yes.
No
Yes
Sometimes
Have you had unprotected sex (no condoms) since your last menstrual period? No / Yes Any missed birth control pills? Plan B taken in last year?NoNoYes Yes. Are you currently using contraception? Any previously used contraceptive method?
Any other health care concerns you would like to discuss?
No
(please list)
PHYSICAL EXAM
Name
ID#
Allergies,
Current meds.
Ht.
Wt.
BP
Pulse
GENERAL PHYSICAL EXAM:
indicated
not indicated
Thyroid
Lungs
Extremities
Other
BREAST EXAM:
Describe FibrousD/C R: NlAbnlCystic mass L: NlAbnlFibrousCystic massD/CDescribe indicated
Nl
Describe
L
Describe
PELVIC EXAM;
Herpes
Vagina: NlAbnl D/C Condyloma Other: Describe Cervix:
Describe
Cervicitis NlErosionEversion Abnl
Mucopurulent D/C Cervical motion tenderness Other: Uterus:
NlEnlargedNodular Smooth Abnl MLRLOther: Ant/post Adnexal:
Mass
Abnl R: NlTender massDescribe Abnl L: NlTender massDescribe
NlBloodHemorrhoid AbnlMassOther: Fissure
Mass
Other
TESTS:
Chlamydia
Viral culture
(Topical Acetic Acid (HPV)
Gonorrhea
HCG
RPR
Saline/KOH
(initials)
Serum HSV
other
GYN lab notification by letter/ phone/consult
Pap (conventional/thin prep) Gonorrhea
GYN lab notification by letter/ phone/consult
ASSESSMENT
Contraception Method
Gardasil vaccine recommended. Other treatment
Follow up
BSE instruction
HEALTH EDUCATION:
ECP
STI information
HIV risk factors
BCP new start/renewal/consent
Ring/new start/renewal/consent
STI information Smoking cessation/alcohol Osteoporosis prevention Safe sex Patch/new start/renewal/consent
BCP new start/renewal/consent
Other
Safe sex
Nutrition/exercise
Ring/new start/renewal/consent HEALTH EDUCATION: Diaphragm instruction Info for condoms/spermicide
Other
Nutrition/exercise Depo Provera/new start/renewal/black box warning/consent Domestic Violence
Date
Month Day Year
Date
9/09cm
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GYN FORM

GYN HISTORY

PHYSICAL EXAM

GENERAL PHYSICAL EXAM:

BREAST EXAM:

PELVIC EXAM;

TESTS:

HEALTH EDUCATION: