33 Y.O. female with chlamydia 28 Y.O. with abnormal vaginal bleeding 37 with a right upper breast lump template is attached ? to be done by 4/11/2

Encounter date: ________________

Patient Initials: ______ Gender: Female__________ Transgender ____ Age: _________

Weight __________ Height _________ Pregnant: _________Gestational Age: __________

Last US Date: ________________

Chief Complaint :

HPI:

Menstrual history:

Age at menarche:

Last menstrual period: Menstrual pattern: Cycle length:

Duration of flow: Amount of flow: Bleeding pattern:

Associated pain (dysmenorrhea):

Break through bleeding:

Pre menopause/menopause: yes no

Vasomotor symptoms: yes no, if yes explain________________________________________

Hormone replacement therapy: yes no

Contraception: yes no Current method; satisfied with method? Yes no

Previous methods, including complications, reasons discontinued?

Cervical and vaginal cytology:

Most recent Pap smear result

History of abnormal Pap smears? If so, nature of diagnosis, treatment, and follow-up

History of sexually transmitted infections:

Vaginitis?

History of pelvic inflammatory disease?

Any difficulty conceiving in past? If so, prior evaluation and treatments

Sexually active:

History of sexual abuse or sexual assault?

Obstetric history:

G

T

P

A

L

Describe any maternal, fetal, or neonatal complications?

Allergies (Drug/Other):

PMH:

Current or past illnesses

Hospitalizations

Past surgical history

Current Meds:

Family Hx:

Immunization: Use attach table to document.

Social history: __ Married __Widowed __Single __ Divorced __Cohabitating Partner

Lives: ___ Home ___Alone ___ Family ___Caretaker __ ACLF ___ SNF ___

Other: Smoke ____ ETOH _________ Recreational Drug Use __________

Review of Systems:

General:

HEENT:

Eyes-

Ears-

Neck-

Nose-

Mouth-

Throat-

Lungs-

Cardiovascular-

Breast-

GI-

GU/Male/female genital-

Neuro-

Musculoskeletal-

Activity & Exercise-

Psychosocial-

Derm-

Nutrition-

Sleep/Rest-

Physical Exam

General:

HEENT: __________________________________________________________________________________________

Pulmonary: _________________________________________________________________________________________

Cardiovascular ______________________________________________________________________________________

Breast_____________________________________________________________________________________________

Abdomen __________________________________________________________________________________________

Rectal _____________________________________________________________________________________________

Male/female genital __________________________________________________________________________________

External genitalia:

Discharge:

Smell:

Pelvic pain:

Lesions, pruritus or burning:

Cervical motion:

Fundus height:

Musculoskeletal _____________________________________________________________________________________

Neuro _____________________________________________________________________________________________

Derm______________________________________________________________________________________________

Psych_____________________________________________________________________________________________

Misc ______________________________________________________________________________________________

Assessment

Significant Data/Contributing Dx/Labs/Misc

(Differential Diagnoses)

1.

2.

3.

4.

5.

6.

Plan (Consider: Diagnostic, Therapeutic, Educative, Referrals, & Follow-up)

1.

2.

3.

4,

5.

6.

Signature__________________________________________________________________________________________

Cite current evidenced based guideline(s) used to guide careMandatory)

1._____________________________________________________________________

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