Review of Systems Reason for Visit Past Gynecologic
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REVIEW OF SYSTEMS Patient Name Date DOB Height Weight REASON FOR VISIT Why are you seeing the doctor today? ________________________________________________________________________________________ Have you been treated for this problem in the past? Yes No If yes, please explain ______________________________________________________________________________________________________ Have you had any recent radiology or laboratory studies? Yes No If yes, please indicate where, when, and type of study __________________________________________________________________________ PAST GYNECOLOGIC HISTORY Please indicate if you have received treatment for the conditions below, or if you are currently receiving treatment. Yes No Yes No Abnormal Pap HPV (Human Papillomavirus) Other Gynecologic Problems _______________________________________________________________________________________________ Are there any other medical problems that we should be aware of? ______________________________________________________________ _________________________________________________________________________________________________________________________ Are you currently pregnant or could you possibly be pregnant? Yes No Date of Last Menstrual Period ____________________/ / Do you/have you taken female hormones? Yes No Oral contraceptives? Yes No Type of contraception: _____________________________ Total number of: Pregnancies ________ Term Births ________ Pre-Term Births ________ Elective Abortions ________ Miscarriages ________ C-sections ________ REVIEW OF SYSTEMS Do you CURRENTLY have any problems related to the following systems? General Colorectal Cardiovascular Skin Fever Hemorrhoids Chest Pain Rashes Weight Change Anal Fistula Palpitations Lumps Hormonal Problems Psychological Fluid/swollen Extremites Musculoskeletal Joint Pain Anxiety Gynecology Joint Pain Pain in Limbs Depression Abnormal Pap Bone Pain Gastrointestinal Neurological Breast Lump/Pain Muscle Spasm Heartburn Headaches Change in Menses Loss of Function Diarrhea/Constipation Numbness HPV (Human Papillomavirus) Muscle Aches Abdominal Pain Tingling Painful Intercourse Fractured / Broken Bone Nausea/Vomiting Seizures STD (Sexually Transmitted Disease) Trouble Swallowing Weakness Vaginal Discharge GI Bleed Vaginal Dryness REVIEW OF SYSTEMS REVIEW OF SYSTEMS (CONTINUED) Do you CURRENTLY have any problems related to the following systems? Eyes Urological Ears, Nose, Throat Respiratory Hematological/lymphatic Glasses/contacts Blood in Urine Dificult Swollowing Shortness of Breath Anemia Cataracts Erectile Dysfunction Ear Pain Sleep Apnea Bleeding Problems Glaucoma Painful Urination Seasonal Allergies Wheezing Clotting Disorder Eye Injury Frequent Urination Hard of Hearing Cough Lymph Problems Incontinence Large Lymph Gland Patient Name Date Signature of Patient / Guardian Date FOR OFFICE USE Reviewed By Date.