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    OBGYN History Template

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    dalicuse
    The patient presented for an initial visit with a female provider. The chief complaint and history of present illness were not provided. A review of systems was negative. The patient's perspectives and expectations for treatment were not documented. A thorough woman's health and social history was taken including menstrual, sexual, obstetric, medical, surgical, family, and social histories. Relevant details were obtained to guide the patient's care.

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    OBGYN History Template

    Uploaded by

    dalicuse
    66 views2 pages
    The patient presented for an initial visit with a female provider. The chief complaint and history of present illness were not provided. A review of systems was negative. The patient's perspectives and expectations for treatment were not documented. A thorough woman's health and social history was taken including menstrual, sexual, obstetric, medical, surgical, family, and social histories. Relevant details were obtained to guide the patient's care.

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    OBGYN_history_template

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    The patient presented for an initial visit with a female provider. The chief complaint and history of present illness were not provided. A review of systems was negative. The patient's perspectives and expectations for treatment were not documented. A thorough woman's health and social history was taken including menstrual, sexual, obstetric, medical, surgical, family, and social histories. Relevant details were obtained to guide the patient's care.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    66 views2 pages

    OBGYN History Template

    Uploaded by

    dalicuse
    The patient presented for an initial visit with a female provider. The chief complaint and history of present illness were not provided. A review of systems was negative. The patient's perspectives and expectations for treatment were not documented. A thorough woman's health and social history was taken including menstrual, sexual, obstetric, medical, surgical, family, and social histories. Relevant details were obtained to guide the patient's care.

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    Introduce self

    Which name do you prefer to be called?


    Chief complaint:
    HPI:

    ROS:
    Gen: No fever, chills, weight changes, malaise
    Neuro: No headache, dizziness, syncope, weakness, changes in sensation***
    CV: No chest pain or palpitations
    Resp: no SOB, cough, wheezing
    GI: no nausea, diarrhea, constipation, reflux, blood in stool
    GU: no vaginal discharge, vaginal bleeding, dysuria, hematuria, dyspareunia
    Musculoskeletal: no back pain, joint pain, arthritis
    Psych: no SI/HI, depressed mood, anxiety
    Skin: No pigmentation changes, rash, itching

    Perspective:
    What worries you the most about your symptoms?
    What do you think is causing your symptoms?
    How has your symptoms affected your day-to-day life?
    What are your expectations on the treatment that we will provide you?

    Going to ask you some questions that are more personal. This is so we can have a better idea of your
    womanly health so we can better take care of you. Everything you tell me will not go outside of your
    healthcare team, and will only be used to better improve your health.

    Gyn:
    - menstrual period:
    o LMP
    o How long do they last
    o how many pads do you use
    o are they regular
    o how many days in between
    o how old were you when you started menarche
    - Last pap smear?
    - Any history of abnormal pap smears?
    - Last mammogram?

    Sexual history:
    - number of partners in last 12 months?
    - male or female or both?
    - Number of current sexual partners?
    - Oral, anal, vaginal?
    - Condoms/protection?
    - Any forms of contraception?
    - Any history of STDs?
    - Have you been tested for HIV?

    OB:
    - how many times have you been pregnant?
    - can you tell me about those pregnancies?
    - At what gestational age did you deliver? Method?
    - Any problems with any of those pregnancies?
    - Any miscarriages? Abortions? Ectopic pregnancies?
    - Besides those, any other procedures where they had to perform instrumentation on the uterus?

    PMH:
    - any other major health problems?
    - high blood sugars or blood pressures?
    Major hospitalizations/illnesses:
    - any major illnesses where you have been hospitalized?
    Meds:
    - doses and frequency of each
    Allergies:
    Surgeries:
    Family history:
    - major illnesses?
    - cancer?
    Social:
    - drinking
    - smoking or other tobacco products
    - other drugs
    - Do you have any concerns at home about your safety?
    - What is your occupation?
    - Who lives with you at home?
    Anything you think we should know to better take care of you?
    Questions?

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