Female Medical Exam
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1FEMALE MEDICAL EXAM
Name ________________________________________________
Age _________________
Date _____________________
ALLERGIES
❏
OFFICE TESTS
______________________________________
NKDA
❏ Pregnancy Test
❏ Positive
SUBJECTIVE
❏ Negative
Chief complaint/Purpose of visit:___________________________________________________
❏ Urinalysis
_____________________________________________________________________________
❏ Leukocytes
G ______ P ______ TAB ______ SAB ______ Ectopic ______ LMP ______ LNMP _______
❏ Nitrites
Current BCM ____________________ Since __________ Date of last pill/injection __________
❏ Protein
❏
❏
Currently breast feeding?
Yes
No
❏ Glucose
BCM desired __________________________________________________________________
❏ Wet Mount
Last unprotected intercourse (UPIC) __________________ EC used? ___________________
❏ Candida
❏
❏
STD risk factors (past 12 months or since last visit/risk assessment):
None
Not assessed
❏ Trich
❏ Known/suspected exposure
❏ Inconsistent condom use (<100%)
❏ Clue Cells
❏ New or >1 partner
❏ Personal/partner IDU
❏ WBCs: ____________
❏ Possible non-monogamous partner
❏ Hx of STD diagnosis
-
+
Vaginal pH: _____ Amine
Staff signature: ____________________________ Title: _______________ Time: _________
LAB TESTS
Present history: ________________________________________________________________
❏ Pap
❏ Ct
_____________________________________________________________________________
❏ GC
❏ HIV
❏ Syphilis
❏ Glucose
❏ GTT
❏ Cholesterol
OBJECTIVE
❏ Lipids
❏ LFTs
❏ Urine C/S ❏ CBC
Vital signs: WT _______ HT _______ BMI _______ BP _______ T _______ P _______
❏ Herpes
❏ Mammo
PHYSICAL EXAM
NL
ABN
Not Done
Description
Other lab tests: __________
Neck/Thyroid
_______________________
Heart
Lungs
Breast ❏ BSE reviewed
Abdomen
EDUCATION
GYN: Ext. genitalia
❏ Contraceptive options
Urethral meatus
❏ Method: ______________
Urethral/bladder
❏ Warning signs/risks
Vagina
❏ Side effects
Cervix
❏ Usage
Uterus
❏
Emergency contraception (EC)
Adnexae
❏ Condoms/spermicides
Anus/perineum
❏ Safer sex/STI
❏ Alcohol/drug use
Other: ________________________________________________________________________
❏ Preconception planning
_____________________________________________________________________________
❏
Physical exam not performed: ❏ Not indicated ___________ ❏ Patient declines __________
Parental involvement (if <18)
❏ Mammogram (if >40)
❏ Done elsewhere _________ ❏ Records request __________
MEDICAL DECISION MAKING
Assessment: __________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Plan: ❏ BCM _________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
❏ Referral/ ❏ Consultation ____________________________________ ❏ RTC _______ /PRN
Rx dispensed _________________________________________________________________
>50% of visit was counseling/coordination of care. Clinician time: ________________________
Clinician signature: ________________________________________________________
Print name:_______________________________ Date/time:_______________________
April 2008
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