Vicente Sotto Memorial Medical Center

Department of Obstetrics and Gynecology

OB-GYNE INTERN’S/CLERCK’S HISTORY & PHYSICAL EXAMINATION SHEET

General data: _______________________________________________________

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Chief complaint: ___________________________________

Informant & percentage reliability: ____________________

History of present illness: ____________________________________________

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Past medical history: [Hospitalization] ___________________________________

[Surgeries] __________________________________________________________
[Illnesses] ___________________________________________________________

Family history: Hypertension ___ *[P]*[M] Diabetes Mellitus ___ [P][M] Asthma ___
[P][M] Cancer ___ [P][M] Others _____________________ [P][M]
*[P]- Paternal side, *[M] – Maternal side

Menstrual history: Menarche: ______ Interval: ________ Duration:_______

Amount: _______ Symptoms: ________

Sexual & Contraceptive history: Coitorche: ________ Sexual Partner: ________

[Contraceptive]:Pills ___ IUD ___ Implanon___ Condom ___ Rhythm ___ Others___
___ Pap Smear ____ STI
Obstetric history: G ___ P ____ (__ __ __ __)
LMP: ____________ PMP: ___________ AOG: ___________ EDC: ____________
Pregnancy Pregnancy Year Gestation Sex Birth Present Complications
Order Outcome Completed Weight Status Abnormalities
(weeks)

VSMMC-MSD-OB.GYNE-F-3 Rev. 0
June 15, 2018
Prenatal history (if applicable): ____ # of visits _____ Provider _____ Usual BP
____ Iron ____Calcium ___ Other meds ___________________ History of illness

Personal/ social history: Occupation:________ Income:_____ Education:_______

Allergies: ____________ Illicit drug use:___ Smoking:___ Alcoholic drinking:______

P H Y S I C A L E X A M I N A T I O N

General survey: _____________________________________________________

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Vital signs: BP: _____ HR: _____ RR: _____ Temp: _____ O2 Saturation: _____
Wt.: _____ Ht.: _____ Pain scale: _____ BMI: _______ ECOG (if applicable): _____

HEENT: ____________________________________________________________

Breast: ____________________________________________________________

Chest & lungs: ______________________________________________________

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Cardiovascular: _____________________________________________________
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Abdomen: FH ______ FHT _____ EFW _____

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Pelvic exam: Speculum Exam: __________________________________________

Internal Examination/Bimanual Pelvic Examination: __________________________
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Rectovaginal examination: ______________________________________________

Rectal exam: ________________________________________________________

Extremities: ________________________________________________________

Central nervous system: ______________________________________________

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IMPRESSION:

Intern/Clerck-In-Charge

VSMMC-MSD-OB.GYNE-F-3 Rev. 0
June 15, 2018