DEMOGRAPHIC DATA;
- Name
- Age
- Occupation
- Parity
HPI;
A brief statement of the general nature and duration of the complaint, but certain important points should always be enquired about;
- Abnormal menstrual loss
- The pattern of bleeding; Regular or irregular
- Intermenstrual bleeding
- Amount of blood loss; greater or less than usual. The number of tampons or sanitary towels used.
- Passage of blood clots or flooding
- Pelvic pain- Site of pain, nature and relation to periods.
- Anything that aggravates or relieves the pain.
- Vaginal discharge- Amount, colour, odour & presence of blood
Usual Menstrual cycle:
- Age of menarche.
- The usual duration of each period and the length of the cycle.
- First day of the last period.
Previous gynaecological history:
- Previous gynaecological treatments or surgery.
- The last date of a cervical cancer smear.
Obstetric History;
- Number of children with ages and birth weights
- Any abnormalities with pregnancy, labour & puerperium
- The number of miscarriages and gestation at which they occurred.
- Any termination of pregnancy with record of gestation age and any complications.
Sexual and contraceptive History;
- History of discomfort, pain or bleeding during intercourse.
- The use of contraception and the types of contraceptives used.
Previous Medical History;
- Any operations or illnesses and the dates
- Family history
Enquiry about other systems;
- Appetite, weight loss, weight gain
- Bowel activity
- Micturition
- Other systems review
Social History
- Smoking; Type; amount per day
- Alcohol consumption; Type, the daily quantity
- Marital status, number of sexual partners, family problems ought to be discussed.
