CHAPTER 20 The Healthy Female Evaluation

Following are items to consider for inclusion as part of a routine well-woman visit. This is not intended as an all-inclusive list. Some items may vary depending on the woman’s age, health status, and particular risk factors. Past medical history (PMH) and review of systems (ROS) may also be appropriate if indicated. Age and risk-status guidelines for preventive services are available from a variety of sources and authorities.*

HISTORY

HISTORY OF PRESENT ILLNESS (HPI)

Age

Last normal menstrual period (LNMP)

Menopause—age achieved, symptoms

Obstetric history—number of pregnancies, term pregnancies, preterm pregnancies, abortions/miscarriages, living children (GTPAL)

Contraceptive measures and history

Sexual history

Breast lumps, discharge, pain, skin changes

Unusual vaginal bleeding or discharge

Abdominal or pelvic pain or bloating

Urinary symptoms

RISK ASSESSMENT

Cardiovascular—smoking, hypertension, diet, body mass index (BMI), exercise, family history

Cancer—personal/family history of breast, ovarian, or colon cancer; history of sun exposure

Infection—sexually transmitted infection (STI) exposure; tuberculosis exposure; hepatitis vaccine or exposure; tetanus/flu immunization

Metabolic—calcium supplement, family/personal history of osteoporosis; exercise; personal/family history of diabetes mellitus; hearing impairment in older adults

Injury—alcohol, seat belts, guns, family violence

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