Urogenital-Sexual Assessment Data Video Review Tool for Female Client
Client # ______
Sex of student ___ F ___ M
Approx Age of student ___ 20 – 25 ___ 25 – 40 ___ > 40
Approximate age of client ___ 40 – 65 ____ > 65
Ethnicity of student: ___ Caucasian ____ Hispanic ____ AA ___ Asian ___ other or uncertain
Ethnicity of client: ___ Caucasian ____ Hispanic ____ AA ___ Asian ___ other or uncertain
One √ for each question asked or each question answered.
FEMALE SUBJECTIVE DATA
OBSTETRIC HISTORY:
Have you ever been pregnant?
How many times?
How many babies have you had?
Any miscarriage/abortion?
For each pregnancy describe-duration, complications, labor
& delivery,
Do you think you may be pregnant now?
What symptoms are present?
MENSTRUAL HISTORY: Tell me about menstrual periods:
Date of last period?
Age of first period?
How often are periods?
How many days does period last?
Usual amount of flow-light, medium, heavy? Any clotting?
How many pads/tampons are used per hour/day?
Any pain/cramps before or during period?
How is it treated? Does it interfere with daily activities?
Any other symptoms-bloating, cramping, breast tenderness,
moodiness?
Any spotting between periods?
MENOPAUSE:
Have periods slowed or stopped?
Any associated symptoms-hot flashes, numbness & tingling,
headache, palpitations, drenching sweats, mood swings, vaginal
dryness, itching?
If hormone replacement-how much? Is it working/ side
effects?
How do you feel about going through menopause?
SELF-CARE BEHAVIORS:
How often do you have a gynecologic / female checkup?
Last PAP (papanicolaou) smear? Results?
Has your mother ever mentioned hormone therapy during
pregnancy?
Questions
asked
Follow-up
questions
Client
reported
URINARY SYMPTOMS:
Any problems with urinating?
Frequency & small amounts? Cannot wait to urinate?
Any burning or pain with urination?
Awaken during night to urinate?
Any blood in urine?
Urine dark, cloudy, foul smelling?
Any difficulty controlling urine or wetting yourself?
Urine leakage with sneeze, laugh, cough, bearing down?
VAGINAL DISCHARGE:
Any unusual vaginal discharge? Increased amount?
Character or color-white, yellow-green, gray, curdlike, foul
smelling?
When did this begin?
Is discharge associated with vaginal itching, rash, pain with
intercourse?
Taking any medications?
Family history of diabetes?
What part of menstrual cycle are you in now?
Use a vaginal douche? How often?
Use feminine hygiene spray?
Wear nonventilating underpants, pantyhose?
Treated discharge with anything? Results?
PAST HISTORY:
Any other problems in genital area? Sores or lesions-now or
in past?
How were these treated?
Any abdominal pain?
Any past surgery on uterus, ovaries, vagina?
SEXUAL ACTIVITY:
Do you have any questions about sexual relationships or
your health?
Are you in a relationship involving sex now?
Are aspects of sex satisfactory to you & partner?
Satisfied with way you & partner communicate about sex?
Satisfied with your ability to respond sexually?
Do you have more than one sexual partner?
What is your sexual preference-relationship with a man,
woman, or both?
CONTRACEPTIVE USE:
Currently planning a pregnancy or avoiding pregnancy?
Do you & partner use contraception? Which method? Is this
satisfactory?
Do you have any questions about this method?
Which methods have you used in past? You & partner
discussed children?
Have you ever had any problems getting pregnant?
SEXUALLY TRANSMITTED DISEASE CONTACT:
Any sexual contact with partner having an STD-gonorrhea,
herpes, AIDS, chlamydial infection, venereal warts, syphilis?
When? How was this treated?
Were there complications?
STD risk reduction-any precautions to reduce risk of STDs?
Use condoms with each sexual encounter?
Total # questions
Did not identify anywhere on video that student asked any similar questions. ___________
Other comments:
________________________________________________________________________________________
Initials of reviewer _________