Female History Checklist

I will be asking you some personal questions which I ask all of my patients to obtain a thorough womans health history. 1)Past Gynecologic History Menstrual History Sexual History Contraceptive History STI and PAP History Other Gynecologic issues Breast Health 2) Past Obstetrical History 3) Domestic Violence Screen Past Gynecologic History Menstrual History When was your last menstrual period? How old were you when you had your first period? How often does your period come? Every month? How long does your period last? Do you have heavy bleeding with your periods? How often do you need to change pads or tampons each day? Do you have bleeding between periods or after sex? Do you have pain with your periods or before your periods? At what age did your periods stop? Sexual Hx Are you currently having sex? Are you currently sexually active? At what age did you start having sex? In your life, with how many people have you had sex? Are you sexually active with men, women or both? Do you have more than one partner? Do you have vaginal, oral or anal intercourse? Do you have any difficulty with sex? (libido, arousal, lubrication/vaginal dryness, orgasm) Do you notice any changes in your sexual activity/function since the last visit/ over the past year? Contraceptive Hx Are you currently using anything to prevent pregnancy (or for birth control)? Have you used anything in the past? Types of contraception Does your partner use condoms? Do you use condoms all the time? Do you use a vaginal or dental dam? Have you ever had Gonorrhea, Chlamydia, Herpes, Syphilis, HIV, Hepatitis, HPV or genital warts? PAP Hx Have you ever had a PAP smear performed? When was your last PAP smear? Was it normal? Have you ever had a biopsy or procedure on your cervix for abnormal cells? Have you ever received Gardisil or other vaccine for HPV?

Other Gyn issues Have you ever been told that you have a fibroid or ovarian cysts? Chronic Pelvic Pain and Endometriosis o Do you experience pain with your period or with intercourse? o Do you experience pelvic pain? Have you ever had difficulty getting pregnant or used any medications to become pregnant? Menopause Have you ever experienced hot flashes, difficulty sleeping or vaginal dryness? How are these affecting your life? Use of exogenous hormones (HRT/ERT) or SSRIs Have you ever used any medications for menopause/symptoms? Use of complementary, herbal, homeopathic, and other remedies o Have you used any herbal medicines or supplements for menopausal symptoms?

Female History Checklist

Ask about post-menopausal bleeding (early symptom of endometrial/uterine cancer) o Have you experienced any vaginal bleeding in the past year? Incontinence (urine or stool) Do you ever pass urine or stool when you laugh or cough? Do you ever pass urine or stool unexpectedly? Pelvic Organ Prolapse Do you feel pressure or bulging in the vagina? Breast Health Do you perform self breast exams? If age > 40, When was your last mammogram? What was the result? History of breast problems or disease Have you ever had a breast cyst or mass? Have you ever noticed nipple discharge? Do you experience breast pain? History of breast surgery Have you ever had any surgery on your breast? (biopsy, removal of mass, enlargement or reduction) Past Obstetrical History Have you ever been pregnant? How many times? How many living children do you have? Can you tell me about each pregnancy? Lets start with the first one Was it a live birth? Was it a miscarriage, abortion, ectopic pregnancy or still birth? Were there any complications during the pregnancy? (diabetes, high blood pressure, IVF pregnancy, etc) Was the baby born around his/her due date? Was the baby born vaginally or by cesarean section? Were there any complications during the birth or after the birth? (bleeding, forceps, fever) Repeat for each pregnancy Gravitdity Total number of pregnancies Includes live births (full term, preterm), miscarriage, termination/abortion/ectopic pregnancies Parity TPAL Term (>37 wks) Pre-term (<37 wks but >20 wks) Abortions/ectopics/miscarriages Living (all living children) Domestic Violence Screen Now I would like to ask you some questions about your safety. These questions are personal and I ask them of ALL my patients. Have you ever experienced physical, verbal or sexual abuse? Have you ever been hit, punched, or forced to have sex? Do you feel safe at home? Do you feel safe in your current relationship? PROCEED TO PAST SURGICAL HISTORY, MEDICATIONS, ALLERGIES, ETC