Well Woman Exam – Subjective HPI

CC: Obtain a complete history of the pt's health concern, complaint, or illness.

PH: List any medical problems and hospitalizations.

PSH: Has the pt had any surgeries or minor procedures?

Allergies: Any known drug allergies?

Medications:

Is the pt currently taking any drugs, prescribed, or over-the-counter?
Is the pt taking any herbals, supplements, or vitamins?
FH: Is there a history of breast cancer, ovarian cancer, colon cancer, diabetes mellitus, heart disease, hypertension, hyperlipidemia, or osteoporosis?

SH:

Does the pt use alcohol, tobacco, or drugs?
If yes, quantify the amounts, the frequency, and for how long.
Ob/Gyn:

Age of first menstruation (menarche)?
Frequency, duration, and blood flow of menstrual period?
Age of first sexual encounter (coitarche)?
Number of lifetime sexual partners?
Gender of partners: Male, female, or both?
Age of first pregnancy?
Number of pregnancies, deliveries, abortions?
History of sexually transmitted infections?
* Methods of contraceptives used in the past and in the present (if sexually aclivel?

• Has the pt ever had a Papanicolaou test (Pap)?
O If yes, was it normal?

GHM:

° Review the pt's immunization record and last tuberculosis test.
Has the pt had fecal occult blood test, colonoscopy, DEXA scan, or mammogram if age appropriate?
ROS: Review of systems
Check vital signs