Initial Gynecolgic Consult
Connect Listen Empathise Ask Review and check

Patient Demographics:
Previous MD
Chief Complaint
Problem List
History of Present Illness
Past History
Anesthetic Problems
Transfusions? Yes/No
Sleep Apnea? Yes/No
OB/GYN History
G P T A (SA TA) L
Menses
Pap Always Normal Abnormal       Cytology Number
STDs
Contraception
YES/NONow
Past
Blood type
Problems in Pregnancy
Menopause
Calcium & Vitamin D
Medications
Allergies
Latex Allergy? Yes/No
Adverse Reactions
Family History
Mom Dad Wife Husband Son Daughter Sis Bro Aunt Uncle Grandma Grandpa
BP CVA MI Lipid DM Thyr Ca Breast Ca Glauc GI GU MSK Resp Allergy EtOH Psych
Lifestyle
Smoking (YES/No) Never Quit Occ Now /day       Start:       Quit:
Caffeine /day
Alcohol (YES/No) /wk
Drugs IVDU
Diet
Fitness
Social History
Relationship Status Single Married Common Law Separated Divorced Widowed
Partner's Name
Sexual Partners M F Both None
Sexual Concern
Assault/Abuse Yes/No
Counselling?
Education
Occupation
Examination
Measurements HT (cm)       WT (kg)       (kg/m2)       BP (sitting)       
Routine Exam
H&N (N/Abn)       Chest(N/Abn)       CVS(N/Abn)       Abd(N/Abn)      
Pelvic(N/Abn/Disc)      
QTip (>30, <30)    Post Void Residual(N less than 100cc)   
Assessment:
Plan:
Procedure:
Subject: