HEALTH RECORD
CHRONOLOGICAL RECORD OF MEDICAL CARE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
DATE
Wt:
Ht:
BMI
B/P:
T:
P:
R:
SaO2
Peak Flows
Allergies:
Meds:
WOMEN’S HEALTH HISTORY
Please answer the following
questions. HEALTH ASSESSMENT
Age:
WELL-WOMAN
 When was your last mammogram?
 When was you last period?
 When was your last PAP test?
 1 yr.
 2 yrs.
 >3 yrs
Were the results normal?
 Yes  No
 Have you ever had an abnormal PAP test?
 Yes  No
 How often do you usually get your period?
Every
days
 Are your periods usually regular?
 Yes  No
 How many days do your periods usually last?
days
The blood flow is:
 Light  Moderate  Heavy
 Do you have any bleeding between periods?
 Yes  No
 Do you have any vaginal discharge?
 Yes  No
 Are you sexually active?
 Yes  No
If yes, do you and your partner use birth control?
 Yes  No
 Have you ever had a sexually transmitted disease (STD)?
 Yes  No
 Has your mother ever been exposed to DES?
 Yes  No
 Have you ever used fertility medicines?
 Yes  No
 Do you have hot flashes?
 Yes  No
 Are you on hormone replacement?
 Yes  No
 Do you smoke?
 Yes  No
 How often do you perform self breast exams?
 Less often than monthly
 Monthly
 Do you have a history of breast problems?
 Yes  No
 Have you ever been abused?
 Yes  No
 Is there any family history of:
Breast Cancer?
 Yes
 No
Colon Cancer?  Yes
 No
Uterine Cancer?
 Yes
 No
Ovarian Cancer?  Yes
 No
Other Cancers?
 Yes
 No
Osteoporosis?
 Yes
 No
Heart Disease?
 Yes
 No

Do you have any allergies?
 Yes
 No (If yes, please list)

On a scale of 0 to 10, (with 0 = no symptoms; 10 = severe symptoms), how would you
describe the following (please circle):
Pain during you usual period:
0 1 2 3 4 5 6 7 8 9 10
PMS (premenstrual tension syndrome): 0 1 2 3 4 5 6 7 8 9 10
 If you have been pregnant, please indicate how many:
Pregnancies:
Full-term live births:
Premature births:
Abortions:
Living Children:

Please list any other concerns:
PATIENT'S IDENTIFICATION (USE THIS SPACE FOR MECHANICAL IMPRINT)
RECORDS MAINTAINED AT:
PATIENT’S NAME (LAST, FIRST, MIDDLE INITIAL)
RELATIONSHIP TO SPONSOR
STATUS
SPONSOR’S NAME
DEPART./SERVICE
SEX
RANK/GRADE
ORGANIZATION
SSN/IDENTIFICATION NO.
CHRONOLOGICAL RECORD OF MEDICAL CARE
NHBRREM FORM
DATE OF BIRTH
STANDARD FORM 600 (REV.5-84)
FIRMR (41 CFR) 201-45.505
CHRONOLOGICAL RECORD OF MEDICAL CARE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
Naval Hospital Bremerton, Family Practice Clinic
WOMEN’S HEALTH EXAM
HEENT
Nl 
TMs clear mobile; Pharynx pink; PERRLA  Abl
THYROID
Nl  no mass nodules, or tenderness  Abl
SKIN
Nl 
Warm, pink, dry, no rashes
LUNGS
Nl 
Clear, no wheezes, rales, rhonchi
HEART
Nl 
RRR, no murmur, nl S1S2
 Abl
 Abl
 Abl
ABDOMEN
Nl 
Soft, no mass, non-tender, no organomegaly
 Abl
NEURO
Nl 
 Abl
Motor strength, sensation, DTRs symmetric
EXTREMITIES
Nl 
Pink, moist, warm, no edema; Full ROM
 Abl
BREASTS
Nl 
No masses, Non tenderness, No discharge
 Abl
EXTERNAL GENITALIA
Nl 
No lesions, normal hair distribution, normal appearance
Abl 
BLADDER, URETHRA & MEATUS
Nl 
No masses, no lesions, no tenderness, no prolapse / cystocele
Abl 
VAGINA
Nl 
No lesions, no discharge, normal appearance, normal estrogen effect Abl 
 KOH / Wet Prep
 Not performed
CERVIX
Nl 
No lesions, no discharge, normal appearance
Abl 
 Surgically absent
 Parous  Non-parous
 Acetic acid wash
UTERUS
Nl 
Normal size, shape & contour, no masses, no tenderness
Abl 
 Surgically absent
 Ante-flexed  Retro-flexed
ADNEXA
Nl 
No masses, no tenderness, no organomegaly, no nodularity Abl 

Not palpable
ANUS, PERINEUM & RECTAL
 Not examined
Abl 
Nl 
Normal tone, no masses, no hemorrhoids
 Hemoccult Negative  Hemoccult Positive  N/A
A:


Normal Gyn/Pap Exam
Contraceptive Planning
 Hypertension
 Tobacco Abuse
 Not performed
 Hyperlipidemia
Menopause
P:  PAP
 Obesity
 DIabetes
 GC/Chlamydia
 BSE info
 Mammogram
 Flex Sig  Stool guiac cards
 Diet consult
 Premarin 0.625 QD  Prempro .625/2.5 QD
 BCP ____________________ OsCal: 1000 / 1500 mg per day  Prenatal Vit
 Dexa
 Tetanus
 Influenza
 Pneumovax
 Hepatitis B
 Tobacco cessation  Healthwise Handbook
Return for pap  1 year or RTC
Provider signature/Stamp