OBGYN HISTORY OB History – G P (TPAL) G – All pregnancies P Term: >37 weeks Preterm: < 37 weeks and >20 weeks Abortion: < 20 weeks Living: how many children are alive Example: 2009: 39 weeks, (NSVD, VAVD, pLTCS – why?), preE? DM? PPH? Shoulder dystocia? Any other complications or hospitalizations? Was the baby in the NICU? Gender, Weight, Name - If preterm why was someone preterm; If C/S, why did it happen? - If miscarriage or abortion, did it happen on its own or require medication? Or require D&C or D&E? Gyn History Menses: Menarche, frequency q *** days, length ***, #ppd ***, *** pain, intermenstrual bleeding, clots? Pap smear Hx: When was the last one? Any abnormal? Subsequent testing and results? Explain what a Pap smear is and why it’s important Reproductive Desires? Contraception? Protection? Sexual History - Are you currently or have you ever been sexually active? - With men, women or both - Currently with a partner or partners? Number of partners (ballpark)? - Vaginal intercourse? Anal? Oral? Toys or props? - History of STIs? Which ones? when? Were they treated? Were their partners treated? When and if they were last tested for STIs? HIV? Syph? Blood tests or swabs? - Sex: Is it painful? If so, >50% time? With all partners? What’s preventing them from a healthy and pleasurable relationship? Think outside the box What’s the name of your partner? Living with you? Do you feel safe at home? Emotional? Sexual? Physical? Was this a problem in the past? Have you previously received help for this? Hysterectomy? Why? How was it performed (open, laparoscopic, vaginally)? Do they have their cervix? Fallopian tubes? Ovaries? Menopause: Age, symptoms and do they disrupt quality of life? Hormone Replacement Therapy? Or other supplements?
