Date:
Name:
Date of Birth:
Gravida:
Para:
Age:
Well Woman/Chief Complaint:
VITALS: WT:
HT:
BP:
/
P:
R:
PMHx:
Medications:
PSurHx:
OBHx:
SocHx:
Tobacco
EtOH
Illicit Drugs
Allergies:
FamHx:
No
No
No
Ovarian Ca
Breast Ca
Colon Ca
Yes ___________
Yes ___________
Yes ___________
No
No
No
CONSTITUTION
EYES
HEAD/EARS/NOSE/THROAT
CARDIOVASCULAR
RESPIRATORY
GASTROINTESTINAL
GENITOURINARY
MUSCULOSKELETAL
SKIN
BREAST
NEUROLOGIC
PYSCHIATRIC
ENDOCRINE
HEMATOLOGICAL/LYMPHATICS
History of Present Illness:
Student Signature:
GynHx:
LMP
Pap
Mammogram
STDs
T:
No
Yes
Yes _________
Yes _________
Yes _________
Review of Systems (ROS)
Negative
Weight Loss
Weight Gain
Fever
Fatigue
Other:
Negative
Vision Change
Glasses/Contacts
Other:
Negative
Headache
Hearing Loss
Sinusitis Ulcers
Other:
Negative
Chest Pain
Palpitations
Other:
Negative
Wheezing
Hemoptysis Cough
Shortness of breath
Other:
Negative
Diarrhea
Constipation
Bloody stool
Nausea/Vomiting Other:
Negative
Hematuria
Dysuria
Incontinence
Other:
Negative
Arthritis
Muscle Weakness
Other:
Negative
Rash
Ulcers
Other:
Negative
Discharge
Masses
Other:
Negative
Seizures
Syncope
Other:
Negative
Depression
Anxiety
Other:
Negative
Heat/Cold Intolerance
Other:
Negative
Easy Bruising
Bleeding
Edema
Other:
Date:
PHYSICAL EXAM
CONSTITUTION
HEAD/EYES/EARS/NECK/THROAT
CARDIOVASCULAR
RESPIRATORY
BREASTS
GI/ABDOMEN
G/U
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
MUSCULOSKELETAL
o
o
SKIN
LYMPH
NEURO/PSYCH
o
o
o
o
o
Assessment:
Return:
Student Signature:
Day(s)
Pertinent Positives/Negatives
Well developed
Well nourished
Extraocular muscles intact
NO thyromegaly
Trachea midline
No murmurs auscultated
Normal rate
Clear to auscultation bilaterally
No wheezes
No discharge
No dimpling
No masses palpated
Symmetrical
No tenderness/erythema
No masses
No tenderness
No hernia palpated
No hepatomegaly/splenomegaly
No vulvar lesion
Urethral meatus without lesions
No urethral masses
Bladder non-tender
Vaginal mucosa, moist, no lesions, no
discharge
Cervix, no lesion/discharge/no cervical
motion tenderness
Uterus, midline, non-tender, no masses
No adnexal masses/tenderness
Anus/perineum intact without
lesions/masses
Rectal exam normal tone/no masses
Full range of motion in upper/lower
extremities
No weakness
No rashes/lesions/ulcers
No lymphadenopathy in neck/axilla/groin
Alert/oriented to
person/place/time/situation
Normal affect
Plan:
Week(s)
Month(s)
Date: