well women history

Question 1

Menstrual history:

Answer 1

• Age at menarche
• Last menstrual period
• Length and regularity of cycle and duration of bleeding
• Characteristics of flow
• Intermenstrual bleeding
• Recent changes
• Associated symptoms

Question 2

contraceptive history

Answer 2

• Current and past methods and experiences with each
• Satisfaction with current method
• Questions about current method
• Desire to change methods

Question 3

pregnancy history

Answer 3

• Total number of pregnancies (gravida)
• Outcome of each pregnancy (TPAL)
Include year, pregnancy duration, type of birth, weight, complications, gender/weight of baby, is child alive now or, if abortion, length of pregnancy, spontaneous or elective, procedures, and complications

Question 4

Breast and urologic history

Answer 4

• History of any breast masses, cancer, nipple discharge
• Mammogram results and last mammogram, if applicable
• History of urinary tract infections, incontinence or other urinary problems

Question 5

other gynecologic problems

Answer 5

• Infertility
• Fibroids
• Endometriosis
• Ovarian cysts

Question 6

Gynecologic surgeries and procedures

Answer 6

• History of endometrial biopsies, laparoscopic procedures

Include year, reason, complications, outcome

Question 7

sexual history

Answer 7

• Currently sexually active?
• With one or more partners? With men, women, both?
• Satisfaction with sexual function
• High risk for STIs?

Question 8

history of STIs, vaginal or pelvic infection

Answer 8

• History of STIs such as gonorrhea, chlamydia, HSV, syphilis, HIV; when, treatments, complications
• History of frequent vaginal infections such as bacterial vaginosis or yeast; when, treatments, complications
• History of pelvic infections such as PID; when, treatments, complications

Question 9

cervical cancer screening

Answer 9

• Last Pap
• Pap intervals
• History of abnormal Paps
• History of any procedures like colposcopy, biopsy, LEEP, or cryotherapy
• Follow up after abnormal Pap or procedures

Question 10

abnormal gynecologic symptoms

Answer 10

• Pelvic pain
• Unusual vaginal bleeding
• Pain or bleeding with sex
• Breast masses, pain, skin changes
• Pain with urination, frequent urination, urinary incontinence