GYNAECOLOGY HISTORY & EXAMINATION TEMPLATE

DEMOGRAPHIC DATA; 

  • Name
  • Age
  • Occupation
  • Parity

HPI;

A brief statement of the general nature and duration of the complaint, but certain important points should always be enquired about;

  • Abnormal menstrual loss
  • The pattern of bleeding; Regular or irregular
  • Intermenstrual bleeding
  • Amount of blood loss; greater or less than usual. The number of tampons or sanitary towels used.
  • Passage of blood clots or flooding
  • Pelvic pain- Site of pain, nature and relation to periods. 
  • Anything that aggravates or relieves the pain.
  • Vaginal discharge- Amount, colour, odour & presence of blood

Usual Menstrual cycle:

  • Age of menarche.
  • The usual duration of each period and the length of the cycle.
  • First day of the last period.

Previous gynaecological history:

  • Previous gynaecological treatments or surgery.
  • The last date of a cervical cancer smear.

Obstetric History;

  • Number of children with ages and birth weights
  • Any abnormalities with pregnancy, labour & puerperium
  • The number of miscarriages and gestation at which they occurred.
  • Any termination of pregnancy with record of gestation age and any complications.

Sexual and contraceptive History; 

  • History of discomfort, pain or bleeding during intercourse.
  • The use of contraception and the types of contraceptives used.

Previous Medical History;

  • Any operations or illnesses and the dates
  • Family history

Enquiry about other systems;

  • Appetite, weight loss, weight gain
  • Bowel activity
  • Micturition
  • Other systems review

Social History

  • Smoking; Type; amount per day
  • Alcohol consumption; Type, the daily quantity
  • Marital status, number of sexual partners, family problems ought to be discussed.
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