Subjective/History Elements
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[comment memo="Use with well woman questionnaire"]
[text size="3"] yo G[text size="2"] P[text size="2"] with LMP of [text size="10"] here for well-woman exam.
-Last Pap- [text size="3"] years ago. Results: [select value="normal|other- "][text size="40"]
-Hx of abnormal Pap test: [select value="no|YES"][text size="40"]
-Menarche at age [text size="3"]
-Age of menopause: [select name="menopause" value="not yet reached|started withing past 1/2yrs|"][conditional field="menopause" condition="(menopause).isNot('not yet reached')"] [text size="4"]
[/conditional][conditional field="menopause" condition="(menopause).is('not yet reached')"]
-Frequency of menstrual cycles- every [text size="8"] days?
-Menstrual cycle regularity- [select value="regular|irregular"]
-Duration of menses- [text size="8"] days
-Amount of bleeding on heaviest days- [text size="4"] pads/tampons per day
-Between cycle bleeding- [select value="no|YES"]
[/conditional]-Unusual vaginal discharge- [select value="no|YES"]
-Sexually active- [select name="Sex" value="no|Yes"][conditional field="Sex" condition="(Sex).is('Yes')"]
-Number of sexual partners in past year *[text size="3"]*[/conditional]
-Current method(s) of birth control? [checkbox value="None|Condoms|Withdrawal method|Calendar method (timing intercourse around ovulation)|Birth control pills|Birth control patch (OrthoEvra)|Vaginal ring (NuvaRing)|Injection (DepoProvera)|Diaphragm|Nexplanon|Mirena|Tubal Ligation|Hysterectomy|Post-menopausal|Other-"] [text size="20"]
-History of STD?- [select value="no|YES"]
-Problematic hot flashes- [select value="no|YES"]
-Currently on hormone replacement- [select value="no|YES"]
-Smoking- [select value="no|YES"]
-Hx of breast problems- [select value="no|YES"]
-Last mammogram- [select value="n/a|date-"] [text size="20"]
-Reports being abused- [select value="no|YES"]
-Feels safe at home? [select value="yes|NO"]
-Family history of:
--Breast cancer- [select value="no|YES"]
--Ovarian cancer- [select value="no|YES"]
--Heart disease- [select value="no|YES"]
--Osteoporosis- [select value="no|YES"]
--Diabetes- [select value="no|YES"]
--Other cancers- [select value="no|YES"]
--Colon cancer- [select value="no|YES"]
--Uterine cancer- [select value="no|YES"]

-Allergies- [select value="NKDA|listed-"] [text size="80"]

-Pain during your usual period: [select value="1|2|3|4|5|6|7|8|9|10"]/10
-Pain during sex: [select value="1|2|3|4|5|6|7|8|9|10"]/10
-PMS (premenstrual tension syndrome): [select value="1|2|3|4|5|6|7|8|9|10"]/10

Other concerns: [textarea]

[comment memo="For use in CRDAMC FM Clinic"]
Use with well woman questionnaire
yo G P with LMP of here for well-woman exam.
-Last Pap- years ago. Results:
-Hx of abnormal Pap test:
-Menarche at age
-Age of menopause: -Unusual vaginal discharge-
-Sexually active-
-Current method(s) of birth control?
-History of STD?-
-Problematic hot flashes-
-Currently on hormone replacement-
-Smoking-
-Hx of breast problems-
-Last mammogram-
-Reports being abused-
-Feels safe at home?
-Family history of:
--Breast cancer-
--Ovarian cancer-
--Heart disease-
--Osteoporosis-
--Diabetes-
--Other cancers-
--Colon cancer-
--Uterine cancer-

-Allergies-

-Pain during your usual period: /10
-Pain during sex: /10
-PMS (premenstrual tension syndrome): /10

Other concerns:

For use in CRDAMC FM Clinic
Result - Copy and paste this output: