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Menstrual History Sexual History and Fertility Obstetric History Gynecologic History

Name of patient Age of patient Consent for questioning .

It is important to ask as open a question as possible in this part of the history and to ensure the complaint is understood as everything else follows on from here .

(This will differ slightly depending on the presenting complaint) If pain is involved ascertain site. radiation (if any) and character PQRST for pain Other symptoms CODIERS .

Provoking / Palliating Q .Radiation / Region S .Severity T .Timing (Constant/Intermittent) .Quality R .P .

activities? . family.C ± Chronology of complaints O ± Onset D ± Description / Duration I ± intensity E ± Exacerbation R ± Remission S ± Social: how is work affected. self.

Menarche and menopause 1st day of last menstrual period (LMP) Duration/Length of bleeding (days) Frequency Regularity .

Bleeding between periods (Metrorrhagia) Bleeding after intercourse Spells of no periods in absence of pregnancy (Amenorrhea) Nature of periods Heavy? Clots? Flooding? .

number required. .Pads or tampons used. night sweats Bleeding before puberty. after menopause. Periods painful (Dysmenorrhoea) If menopause: hot flushes.

. Number of partners. used previously.Sexually active. Contraception: on OCP? which one? Contraception: others currently using.

after intercourse: -deep/ superficial -always/ sometimes. result.Physical. Pain during. Difficulty in conceiving. Pap smear: last smear's date. other difficulties during intercourse. .

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HER ƒ ƒ ƒ ƒ ƒ ƒ Knowledge about the fertility period? Have you ever been pregnant? Any h/o PID? H/o ectopic and tubal pregnancy? Do you have any DM or any problems with your thyroid? H/o pelvic surgeries? H/o drug intake? H/o alcohol and smoking? .

STD? H/o abdominal operations? H/o drug intake.HIM ƒ ƒ ƒ ƒ ƒ ƒ ƒ Have you fathered a child before? Occupational history? H/o Mumps? H/o UTI? H/o DM. alcohol and smoking? .

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delivery. how.Possibility of currently pregnant. weights at birth. why. Problems during gestation. . Number of times been pregnant: what month. Bleeding during pregnancy. Was it planned? Number of children.

including the present pregnancy T The number of full-term infants born (infants born at 37 weeks or after) P The number of pre-term infants born (infants born before 37 weeks) A The number of spontaneous induced abortions L The number of living children M Multiple pregnancies .Classifying Pregnancy Status Gravida Para The number of times she has been pregnant.

Did she take any medication? If so. Bleeding during pregnancy.Problems during gestation. what and why? Did she receive prenatal care? If so. delivery. when did she start? What was the duration of the pregnancy? .

What was the duration of the labor? Was labor what she expected? Better? Worse? What was the type of birth? What type of anesthesia. if any was used? Did she have stitches following birth? .

Did she have any complications. such as excessive bleeding or infection following the birth? What was the infant¶s birthweight and sex? What was the condition of the infant at birth? Did the infant cry right away? What was the infant¶s Apgar Score? .

such as suctioning. oxygen or an incubator? Was the baby discharged from the health care setting with her? What is the child¶s present state of Health? .Was any special care needed for the baby.

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‡ Gynecological symptoms ‡ Gynecological diagnoses ‡ Gynecological surgery ‡ Abnormal smears .

The historic taboo associated with the examination of female genetalia has long inhibited the science of gynaecology. . This 1822 drawing by Jacques-Pierre Maygnier shows a "compromise" procedure. in which the physician is kneeling before the woman but cannot see her genitalia. Modern gynaecology has shed these inhibitions.

This gives her one or more chance to ask any questions she has about this new life experience. .Conclusion End an interview by asking if there is something you have not covered that the woman wants to discuss.