Female History - Complete Checklist

How can I address you?

I would like to ask you some questions about your past medical history- have
you ever had a well woman check up?
Would you like a partner or friend to be present?
Lets start with a list of your concerns
Transition statement- Im going to ask you some personal questions about
your gynecological and obstetric history
Menstrual cycle
o Last menstrual period?
o Age of your first period?
o How often do you have them? More or less than a month?
o How long does it last? More or less than a week? (avg 3-5)
o Heavy bleeding? Clots?
o Bleeding/spotting between periods?
o Pain during menses? DYSMENORRHEA
o Pain prior to menses? ENDOMETRIOSIS
Sexual Activity
o Sexually active? Pelvic pain? Pressure(prolapse)? Dysfunction
(arousal/libido/orgasm/dryness)? Spotting?
o # current partners? MWB?
o Contraception- (condom/diaphragm? Pills? Patch/implant/IUD
(insertion can cause bacterial invasion- pelvic inflammation btw)?
Vasectomy? ) always use? # lifetime partners?
Birth control alone- no protection against STI
o Un-safe practices? Vaginal/oral/anal- Dental dam?
o Have you ever been tested for HIV, gonorrhea/chlamydia (annual
test up to 25), herpes, syphilis, hep, HPV-90% of warts, trichomonas
(protozoa- 30% symptoms inflame/itch/burn/sore/smelly colorful
urine- P-V or V-V- easier HIV/pre-term/low birth rate, cure-single
dose abx/no alcohol, can get it again)
Asymptomatic- esp chlamydia- full panel of tests
o Unexpected incontinence urine/stool?
o Inflammation? Fever? Discharge-odor? Chronic pain may make
pregnancy harder later
PAP
o Age 21 ever 1-2 yr screen, >30 every 3 yrs (caveat under 21 if
immunocompromised- transplant/steroid therapy/HIV)
o Ever pap vs Last pap? Normal? Pap finds CIN3 (squamous dysplasia of
cervix- a percentage become carcinoma- cause HPV- incr risk with
smoking)
o HPV (most common STD in US) vaccine- gardisil (virus protein gen
immune response for 6,11,16,18- 100 diff types- so still need Pap)
o Cyst? Fibroid? Biopsy?

Breast
o Self-exam?
o Age >40, last mammogram? Normal?
o Cyst? Mass? Discharge? Pain? Tender?
o Surgery- biopsy? Enlarge/reduction? Mass removed?
Menopause (late 40s/early 50s- or ovaries removed)
o Age? (no period for 12 months)
Perimenopause- 8-10 yrs before, ovaries making less estrogen
(tells bones not to break down/cholesterol regulator)
Premature may require hormone therapy until 50 for risk
o Hot flash? Night sweat? Sleep change? Vaginal Dryness? (Vasomotor)
Headaches- daily/several times/wk, constant low intensity,
head-ache free for months?
Incr risk- osteoporosis, heart disease (coronary artery because
of cholesterol), insomnia, urinary urgency, weight gain, hair
loss/thin, change in libido, joint/muscle pain, racing heart,
memory lapse
o How has it affected life? NURS
o Meds- hormones? SSRI? Herbal?
o Bleed? Post menopausal bleed is increased risk of
endometrial/uterine cancer
Obstetric
o Ever pregnant? How many times (Gravidity?) How old are your
children?
o One by one- live birth? Complications- DM, HTN/preeclampsia
(proteinuria, severe headaches, blurred vision, upper right abd pain
usu under ribs), bleeding/postpartum hemorrhage, fever
o Term (>37 wks)
o C-sect/Vaginal?
Note: G-TPAL (Term, Preterm, Abortion/Miscarriage/Ectopic,
Live)
o Infertility? Difficulty getting pregnant? Used meds? IVF?
Domestic Violence
o Transition- Very important and sensitive question about domestic
violence
o Do you feel save at home? Safe in your current relationship?
o Have you ever been hit abused or forced into sex?
o We have resources like social work to help if you ever want to speak
to us