VIEWS: 7 PAGES: 2 POSTED ON: 3/21/2013
North Cascade Family Physicians 2116 E Section St Mount Vernon, WA 98274 (360) 428-1700 Routine GYN/Breast Exam Please complete the following: Name: _____________________________ Age: __________ Date: ____________________ Number of Pregnancies: _____ Live Births: _____ Miscarriages: _____ Abortions: _____ Last Period: __________ Current Concerns: _________________________________________________________________________________________ Current Contraception or Hormone Replacement Therapy: __________________________________________ Menstrual History: (Check and Describe) No Problems Regular Irregular Pain Heavy Bleeding Postmenopausal Bleeding Describe: _______________________________________________________________________________________ _______________________________________________________________________________________________ Cervical Cancer Screening: Date of last Pap Smear: ________ Frequency of Pap Smears: _______ History of Abnormal Pap? Yes No If yes, when and what treatment of follow up was necessary?: _______________________________________________________________________________________________ Pease check Yes or No to the following: Have you had a pap smear in the last 7 years? (V15.89) Yes No Have you had at least 3 normal pap smears? (V795.0, 795.1, 622.1 233.1) Yes No Did you become sexually active before age 16? (V15.89) Yes No Have you had a new sexual partner since your last pap? Yes No Have you had 5 or more sexual partners in your lifetime? (V15.85) Yes No Are you HIV positive? (O42 or V08) Yes No Prenatal exposure to DES? Yes No Have you had a hysterectomy? Reason: ___________________________ Yes No If you had a hysterectomy, were your ovaries removed as well? Yes No Please check if you have ever had any of the following?: (V12.09) Genital Warts Herpes Chlamydia Gonorrhea Trichomoniasis Syphilis Hepatitis B Pelvic Infection Do you smoke? Yes No If yes, How much? ________________ Have you ever smoked? Yes No If yes, How much did you use to smoke? ____________________ Breast History: Please check all that apply to you and describe No Problems Breast Feeding Pain Leaking Lumps Change in Shape, Skin or Nipple Past Abnormal Mammograms Past Biopsy or Surgery Describe: _________________________________________________________________________________________ Do you perform monthly Self Breast Exams? Yes No Sometimes When was your last mammogram? _______________ What were the results?___________________________ Breast Cancer Risk Factors: Have you ever had Breast Cancer? Yes No Has your mother, sister or daughter ever had Breast Cancer? Yes No Has your aunt or grandmother ever had Breast Cancer? Yes No Have you ever had atypical cells on a breast biopsy? Yes No Did you have your first child after age 30? Yes No Did you start menopause at age 55 or older? Yes No Osteoporosis Risks: Heart Disease Risks: Do you have a history of steroid use? Yes No Are you or have you been a smoker? Yes No Are you or have you been a smoker? Yes No Do you have high blood pressure? Yes No Are you of Northern European descent? Yes No Do you have diabetes? Yes No Are you thin or are you of small build? Yes No Do you have high cholesterol? Yes No Was your menopause younger Do you have a family history of than age 45? Yes No heart disease? Yes No Do you have a family history of osteoporosis? Yes No Which relatives and at what age did they develop Which relatives and at what age did they develop heart osteoporosis? disease? Assessment for Menopausal History Please check any of the following Menopausal symptoms that apply: Have you begun menopause? Yes No At what age did you begin menopause? ______________ Symptoms: None Hot Flashes Vaginal Dryness Mood Swings Menstrual Irregularity Urinary Incontinence/Leakage Have you experienced postmenopausal Bleeding? Yes No If yes, What was the follow up care and diagnosis? ________________________________________________________________________________________
"Routine GYN Breast Exam - North Cascade Family Physicians"