OBGYN – TEMPLATE

GENERAL INFORMATION

1. NAME
2. AGE
3. RACE
4. SEX
5. SOURCE OF HISTORY
6. RELIABILITY OF HISTORIAN

HISTORY OF PRESENT ILLNESS
1. ONSET
2. LOCATION
3. SEVERITY
4. TIMING
5. SETTING
6. AGGREVATING FACTORS
7. RELIEVING FACTORS
8. ASSOCIATED MANIFESTATIONS

FAMILY HISTORY

1. MARITAL STATUS
2. AGE OF DEA BV