Routine GYN Breast Exam - North Cascade Family Physicians by ajizai

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									                                        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?
________________________________________________________________________________________

								
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