WELL WOMAN EXAM

Patient's Name:

Date of Birth:

To help your doctor during today's health exem, please complete items 1 through 11.

1. Age:

First day of last menstrual period:

2. Number of times pregnant:

Number of completed Pregnancies

Date of last pregnancy

If you are under age 55, what method of birth control do you use

lf pills. what kind?

How many years have you used the pills?

Are you planning a pregnancy an the next 6-12 months?

Yes No

3. lf you are through menopause or over age 50. do you take any of the tollowing pills?

Calcium

Yes No

Estrogen (Premarin)

Yes No

Progesterone (Provera)

Yes No

4. Have you had any of the follorring problems

a. Abnormal Pap smears

Yes No

If yes, date

Problem

For abnormality, did you have any of the bllowing done:

Colposcopy

Yes No

Biopsies

Yes No

Surgery

Yes No

b. High blood pressure, heart disease or high cholesterol

Yes No

c. Migraine headaches, blood clot in legs or cancer

Yes No

d. Abdominal or pelvic surgery or special tests

Yes No

If yes, what:

5. Do you have aoy of the following:

a. Problems with present method of birth control

Yes No

b. Bleeding between periods or since periods stopped

Yes No

c. Pain with intercourse or periods

Yes No

d. Any problem with interest in or enjoying intercourse

Yes No

e. A new or enlarging lump in breast

Yes No

F. Change in size/firmness of stools

Yes No

g. Change in size/color of a mole

Yes No

h. Severe headaches

Yes No

i. Pain in the leg, chest, abdomen orJoints

Yes No

j. Trouble falling or staying asleep

Yes No

k. Often feeling down, depressed or hopeless during the past month

Yes No

l. Often having little interest of pleasure in doing things during the past month

Yes No

m. Conflict in your family or relationships, sometimes handled by pushing hitting or cruelty

Yes No

6. Do you have a parent, brother or sister with a history of the following:

a. Cancer of the breast, intestine or female organs

Yes No

b. Head pain or heart attacks before the age of 55

Yes No

If yes to a or b:

Add new row

7. Osteoporosis (than-bone) screening:

a. ls there a history of any relatives with the following stooping over or losing height as they got older. "thin bones" hip fractures

Yes No

If yes, relation

b. Have you had any of lhe following:

Height loss

Yes No

Broken hip or wrist

Yes No

Bone-density test

Yes No

c. Do you take any of the following:

Steroids (prednisone)

Yes No

Medication for thyroid, seizures or thin bones

Yes No

8. Have you ever used tobacco?

Yes No

Add new row

9. Do you drink alcohol?

Yes No

Add new row

10. Prevention

a. Which of the following are included in your diet

b. Exercise

Activity:

Days per week

Time/duration

c. Do you always wear seat belts?

Yes No

d. lf over 30 years old, have you had your cholesterol level checked in the past five years?

Yes No N/A

e. Have you had a tetanus shot in the past 10 years?

Yes No

f. Does your house have a working smoke detector?

Yes No

g. Do you have firearms at home?

Yes No

h. Have you ever had a mammogram?

Yes No

If yes, date of last

where

Have you ever had any abnormal mammograms?

Yes No N/A

If yes, date

problem

For abnormality, did you have any of the following:

Biopsy

Yes No

Cyst fluid drained

Yes No

Surgery

Yes No

i. How many sexual partners have you had in the last 12 months?

ln your lifetime?

j. When is the last tame you had a dental check-up?

11. Please describe any concerns you have

(OFFICE USE ONLY)

Date

Height

Weight

Overweight

Yes No

lf necessary

Temp

Pulse

Resp

O2 sat

Allergies:

Other complaints/hpi:

Physical exam:

no masses

no skin, nipple or axillary changes

As indicated by past medical history (none of the following are specifically recommended by USPSTF):

Diagnosis (#s correspond to problem list):

Plan: All patients:

Handout given and reinforced healthy diet, lifestyle, exercise and safety
Pap smear
Folic acid Rx
Calcium Rx: 600mg/d 1200mg/d
lmmunizations flu, Td (q 10 Yrs)
Recommended dental exam

Over 50 y/o:

Remanded to report postmenopausal bleeding
Cholesterol
Hormone replacement estrogen .0_mg/d progesterone 2.5mg/d
Colon cancer screen: colonoscopy ACBE flex sig stool guaiac x 3

Bone density
Coated ASA: 325 mg/d 81 mg/d
Immunizations: pneumococcal (>65 y/o)

Over 40 y/o:

Mammogram (controversial 40-50 y/o, consider q 2 yrs)

Follow-Up:

Routine visit in

for

Physical exam in

Name:

DOB:

Chart #

Physician Signature

Physician Name

Your information will be encrypted.

WELL WOMAN EXAM - ENGLISH