Periodic Women's Health Assessment - Circle of Life Family Medicine

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Periodic Women's Health Assessment

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Date of Appointment

Patient Name

Patient Date of Birth (Must be MM/DD/YYYY format, including the forward slash)

Occupation

What would you like to address today?

Gynecologic History (Check all that apply or check "none of the above")

Have you ever had an abnormal pap smear?yesno

Date

Chronic pelvic pain

DES Exposure in utero (when your mother was pregnant with you)

Pain with sex (dyspareunia)

Endometriosis or Adenomyosis

Fibroids, uterine

Infertility

Ovarian cyst

Ovarian cyst type

PMS

STI/Sexually Transmitted InfectionsChlamydiaGenital HerpesGonorrheaGenital WartsHepatitis BHepatitis CHIV/AIDSSyphilis

Abnormal Uterine Structure (Uterine Anomaly)

Urinary Incontinence

Vulvar dysplasia (precancer)

Vaginal dysplasia (precancer)

Vulvar Pain/Vulvodynia

Recurrent Vaginitis

Yeast

BV

Pelvic Inflammatory Disease

Other

Other (specify)

None of the above

Are you currently sexually active?YesNo

Are your partner(s)?malefemale

Do you have concerns about sexually transmitted infections?yesnounsure

Do your or your partner have more than one partner?yesno

Do you want to be screened for HIV, the virus that causes AIDS?yesnounsure

Do you have any concerns about sex?yesno

What method of birth control, if any, are you using?

Are you planning a pregnancy in the next year?yesno

Do you have concerns about your menstrual cycle?yesno

Menstrual Status

If pre-menopausal:

When was your last menstrual cycle (if unsure, estimate date)?

Are your periods currently:regularirregular

Is your flow:lightmoderateheavy

How often do you have periods?

How many days do your periods last?

Do you have spotting or bleeding between periods?yesno

Do you have menstrual pain/cramping?nomildmoderatesevere

If post-menopausal:

What medications do you take for this?

Are you experiencing any vaginal bleeding?yesno

Did you use hormones?yesno

If yes, systemiccurrentpast

If yes, vaginalcurrentpast

Date of last pap smear

Facility/Doctor

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*For any medical emergencies at any time please dial 9-1-1.

Find Us
Circle of Life Family Medicine
427 Washington St.
Norwell, MA 02061

Contact
Email
staff@circleoflifefm.com
Phone
(339) 469-2707
Fax
(339) 469-2710

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