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
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference: contributed by Dr. Scott Moses, creator/author of the Family Practice Notebook [link url="//www.fpnotebook.com" memo="fpnotebook.com"][/conditional]