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NameAgeMarital stageDuration of marriageOccupationResidenceDate of admission-

Presenting complaintsHistor o! presenting complaints" Su#sidiar complaints" $aginal disc%arge

Amount- ,Colour- ,Smell-, Character-, Relation to menstruation-, Pruritus-

&rinar s mptoms"
Frequenc -, !rgenc -, !rgent incontinence-, Stress incontinence-, Retention "esitanc -

Regularit -, !se of purgati#es-, An h$ of piles, pain or difficult on defaecation, Rectal %leeding-

)enstrual H*
Age of menarche&ength of the c clePre menstrual s mptomsD smenorrhoea'nter menstrual %leedingPattern of irregularit (#idence of hea# %leedingNo of padsFlooding(ffect on da toda acti#ities Any recent change of menstruationLRMPMenopausal s mptoms-

Past o#stetric H*"

)PC DatesMode of termination of eachA%normalities of * Pregnanc &a%ourPuerperium+irth ,eightsPresent state of health-

Past g necological H*
S mptomsSurger D and CPAP smear-

Coital H*"
Frequenc D spareunia- superficial-deep . pe of pain Post coital %leeding Amount "o, long after Fresh-old

Contracepti+e H*"
Method- male-female Duration Complications

Past medical H*" Past surgical H*" Allergic H*" ,rug H*" -amil H* "
"+P-DM-+A-M'-(pileps Congenital a%normalitiesOther inherited diseasesMiscarriagesStill %irths-

Social %*"