OB/GYN HISTORY AND PHYSICAL EVALUATION FORM
Student: __________________________
Signature: _____________________
Date: _________________
Evaluator: _________________________
Signature: _____________________
Please check: GYN____OB____
Circle the components of H&P that are presented and check the box for observed history items. Use the Strengths and Improvements sections for student feedback.
Please return this form to the student.
☐
Circle the Appropriate Number
Strengths:
History (15 items) - Observed
0------1
Chief Complaint
History of Present Illness (4 elements)
0------1------2------3------4
Review of Systems (2 systems)
0------1------2
Medications/Allergies
0------1------2
Family History / Social History / PMH / PSH
0------1------2------3------4
Areas for Improvement:
☐
0------1------2
OB History / GYN History
☑
0------1------2------3------4------5
Physical Exam (5 systems / items) - Observed
☑
Vital signs / General / GI /
GU / Other
Medical Decision Making (5 items)
N/A---0------1------2
Labs / Diagnostic Test
0------1------2------3
Assessment / Differential Diagnosis / Plan
Each student is required to hand in 2 H&P evaluation forms, one OB H&P and one GYN H&P. One should be submitted in week 4 with the mid-clerkship
evaluation. The other one should be submitted by the end of week 7. At least one of these will be an OBSERVED History & Physical.