Comprehensive Women’s Health History and Physical Template
Encounter date:
Patient Initials: Gender: Age: Race/Ethnicity:
Reason for Seeking Health Care
History of Present Illness (HPI)
Allergies (Drug/Food/Latex/Environmental/Herbal)
Current Perception of Health
Current Medications (including over the counter)
Menstrual History
Age at Menarche
Last menstrual period
Menstrual Pattern
Cycle Length
Duration of Flow
Amount of Flow
Bleeding Pattern
Break through Bleeding
Gynecologic History
History of breast disease, breast feeding, use of self-breast exam, last mammogram (if applicable)
Previous GYN surgery (may include that in surgical history)
History of infertility
History of diethylstilbestrol (DES) use by patient’s mother
Last pap smear, history of abnormal pap
Pre-menopause/menopause
Vasomotor symptoms
Hormone Replacement Therapy
Sexual and Contraceptive History
Current method of contraception
Sexually active
Number of sexual partners
New partners in the 3-6 months
Condom use
History of sexual abuse
History of sexually transmitted infections (STIs)
Obstetric History (including complications)
Past Medical History (PMH)
Major/Chronic Illnesses
Trauma/Injury
Hospitalizations
Past Surgical History
Family Medical History
Social History
Living condition
Marital status
Education
Employment
Occupation
Social supports
Habits (smoking, alcohol use and illicit drugs use)
Health Maintenance
Age-appropriate health promotion/maintenance and screening history
Immunization history
Review of Systems (ROS)
