Female Genitourinary Symptoms
Onset [text] prior to evaluation
Onset while: [text]
Associated Pain (0=none, 10=severe)
Location: [text]
Radiation: [text]
Severity now (0-10): [text]
Severity at worst (0-10): [text]
Duration: [text]
Characterized as: [text].
Pain modifiers
Relieved with [text]
Worse with [text]
[select value="no|YES"] <-- worse with intercourse
Pregnancy History:
Gravida [text]
Para [text]
Ab: [text]
Contraception: [text]
LMP: [text]
[select value="no|YES"] <-- Pregnant Now [text]
Specific Genitourinary Symptoms:
[select value="no|YES"] <-- Abnormal vaginal bleeding [text]
[select value="no|YES"] <-- Vaginal Discharge [text]
[select value="no|YES"] <-- Dysuria
[select value="no|YES"] <-- Frequency
[select value="no|YES"] <-- Hematuria
Associated Symptoms:
[select value="no|YES"] <-- decreased appetite (last ate at [text])
[select value="no|YES"] <-- nausea
[select value="no|YES"] <-- vomiting [text]
[select value="no|YES"] <-- diarrhea
[select value="no|YES"] <-- constipation (last stool at [text])
[select value="no|YES"] <-- black or bloody stool
[select value="no|YES"] <-- fever
Pertinent PMH
[select value="no|YES"] <-- STD
[select value="no|YES"] <-- Ectopic pregnancy
[select value="no|YES"] <-- Endometriosis
[select value="no|YES"] <-- Ovarian Cyst
[select value="no|YES"] <-- Kidney stones
[select value="no|YES"] <-- Urinary tract infections
[select value="no|YES"] <-- Diverticulitis
Pertinent Past Surgeries:
[select value="no|YES"] <-- Appendectomy
[select value="no|YES"] <-- Ceserean Section
[select value="no|YES"] <-- Hysterectomy [text]
[select value="no|YES"] <-- Tubal ligation
[html]<hr>[/html][checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"][html]
reference: contributed by Dr. Scott Moses, creator/author of the <a href="http://www.fpnotebook.com">Family Practice Notebook</a>.[/html][/conditional]
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