Comprehensive Women\u2019s Health History and Physical Template<\/p>\n
Encounter date: <\/p>\n
Patient Initials: Gender: Age: Race\/Ethnicity: <\/p>\n
Reason for Seeking Health Care<\/p>\n
History of Present Illness (HPI)<\/p>\n
Allergies (Drug\/Food\/Latex\/Environmental\/Herbal)<\/p>\n
Current Perception of Health <\/p>\n
Current Medications (including over the counter) <\/p>\n
Menstrual History<\/p>\n
Age at Menarche <\/p>\n
Last menstrual period <\/p>\n
Menstrual Pattern <\/p>\n
Cycle Length <\/p>\n
Duration of Flow <\/p>\n
Amount of Flow <\/p>\n
Bleeding Pattern<\/p>\n
Break through Bleeding<\/p>\n
Gynecologic History<\/p>\n
History of breast disease, breast feeding, use of self-breast exam, last mammogram (if applicable)<\/p>\n
Previous GYN surgery (may include that in surgical history)<\/p>\n
History of infertility<\/p>\n
History of diethylstilbestrol (DES) use by patient\u2019s mother<\/p>\n
Last pap smear, history of abnormal pap<\/p>\n
Pre-menopause\/menopause<\/p>\n
Vasomotor symptoms<\/p>\n
Hormone Replacement Therapy<\/p>\n
Sexual and Contraceptive History<\/p>\n
Current method of contraception<\/p>\n
Sexually active<\/p>\n
Number of sexual partners<\/p>\n
New partners in the 3-6 months<\/p>\n
Condom use <\/p>\n
History of sexual abuse<\/p>\n
History of sexually transmitted infections (STIs)<\/p>\n
Obstetric History (including complications)<\/p>\n
Past Medical History (PMH)<\/p>\n
Major\/Chronic Illnesses<\/p>\n
Trauma\/Injury<\/p>\n
Hospitalizations<\/p>\n
Past Surgical History<\/p>\n
Family Medical History<\/p>\n
Social History<\/p>\n
Living condition<\/p>\n
Marital status<\/p>\n
Education<\/p>\n
Employment<\/p>\n
Occupation<\/p>\n
Social supports<\/p>\n
Habits (smoking, alcohol use and illicit drugs use)<\/p>\n
Health Maintenance <\/p>\n
Age-appropriate health promotion\/maintenance and screening history<\/p>\n
Immunization history<\/p>\n
Review of Systems (ROS)<\/p>\n
General <\/p>\n
Dermatology<\/p>\n
HEENT<\/p>\n
Neck<\/p>\n
Pulmonary System<\/p>\n
Cardiovascular System (CVS)<\/p>\n
Breast<\/p>\n
Gastrointestinal (GI) System <\/p>\n
Genitourinary (GU) System<\/p>\n
Female Genitalia<\/p>\n
Musculoskeletal System <\/p>\n
Neurological System.<\/p>\n
Endocrine<\/p>\n
Psychologic<\/p>\n
Hematologic\/Lymphatic<\/p>\n
Physical Examination<\/p>\n
Vital Signs<\/p>\n
Blood Pressure (BP: Temperature Heart Rate (HR) Respiratory Rate (RR)<\/p>\n
Height Weight Body Mass Index (BMI) Pain <\/p>\n
General Appearance<\/p>\n
Dermatology<\/p>\n
HEENT<\/p>\n
Neck<\/p>\n
Pulmonary System<\/p>\n
Cardiovascular System (CVS)<\/p>\n
Breast<\/p>\n
Gastrointestinal (GI) System <\/p>\n
Genitourinary (GU) System<\/p>\n
Female Genitalia<\/p>\n
Musculoskeletal System <\/p>\n
Neurological System.<\/p>\n
Endocrine<\/p>\n
Psychologic<\/p>\n
Hematologic\/Lymphatic<\/p>\n
Significant Data\/Contributing Dx\/Labs\/Misc<\/p>\n
Assessment<\/p>\n
Differential Diagnoses (3 minimum)<\/p>\n
Primary Diagnoses<\/p>\n
Plan (For each primary diagnosis, include laboratory\/diagnostic tests, therapeutic\/pharmacological therapy, referrals, and follow-up ordered and patient education done for this visit)<\/p>\n
Diagnoses<\/p>\n
Laboratory\/Diagnostic Studies<\/p>\n
Therapeutic (Non-pharmacological interventions)<\/p>\n
Pharmacological Therapy<\/p>\n
Patient Education\/Anticipatory Guidance<\/p>\n
Referrals<\/p>\n
Follow up<\/p>\n
DEA#: 101010101 STU Clinic LIC# 10000000 <\/p>\n
Tel: (000) 555-1234 FAX: (000) 555-12222<\/p>\n
Patient Name: (Initials)______________________________ Age ___________<\/p>\n
Date: _______________<\/p>\n
RX ______________________________________<\/p>\n
SIG: <\/p>\n
Dispense: ___________ Refill: _________________<\/p>\n
No Substitution <\/p>\n
Signature: ____________________________________________________________<\/p>\n
Signature (with appropriate credentials): __________________________________________<\/p>\n
References (must use current evidence-based guidelines used to guide the care [Mandatory])<\/p>\n
5<\/p>\n
Joseph, M. V. (2021). Women\u2019s Health Comprehensive H & P. Copyright \u00a9<\/p>\n","protected":false},"excerpt":{"rendered":"
Comprehensive Women\u2019s Health History and Physical Template Encounter date: Patient Initials: Gender: Age: Race\/Ethnicity: Reason for Seeking Health Care History of Present Illness (HPI) Allergies (Drug\/Food\/Latex\/Environmental\/Herbal) Current Perception of Health Current Medications (including over the counter) Menstrual History Age at Menarche Last menstrual period Menstrual Pattern Cycle Length Duration of Flow Amount of Flow Bleeding […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[10],"class_list":["post-97919","post","type-post","status-publish","format-standard","hentry","category-research-paper-writing","tag-writing"],"_links":{"self":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts\/97919","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/comments?post=97919"}],"version-history":[{"count":0,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts\/97919\/revisions"}],"wp:attachment":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/media?parent=97919"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/categories?post=97919"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/tags?post=97919"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}