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Comprehensive Women’s Health History and Physical Template

Encounter date:

Patient Initials: Gender: Age: Race/Ethnicity:

Reason for Seeking Health Care

History of Present Illness (HPI)

Allergies (Drug/Food/Latex/Environmental/Herbal)

Current Perception of Health

Current Medications (including over the counter)

Menstrual History

Age at Menarche
Last menstrual period
Menstrual Pattern
Cycle Length
Duration of Flow
Amount of Flow
Bleeding Pattern
Break through Bleeding

Gynecologic History

History of breast disease, breast feeding, use of self-breast exam, last mammogram (if applicable)
Previous GYN surgery (may include that in surgical history)
History of infertility
History of diethylstilbestrol (DES) use by patient’s mother
Last pap smear, history of abnormal pap

Pre-menopause/menopause

Vasomotor symptoms
Hormone Replacement Therapy

Sexual and Contraceptive History

Current method of contraception
Sexually active
Number of sexual partners
New partners in the 3-6 months
Condom use
History of sexual abuse
History of sexually transmitted infections (STIs)

Obstetric History (including complications)

Past Medical History (PMH)

Major/Chronic Illnesses
Trauma/Injury
Hospitalizations

Past Surgical History

Family Medical History

Social History

Living condition
Marital status
Education
Employment
Occupation
Social supports
Habits (smoking, alcohol use and illicit drugs use)

Health Maintenance

Age-appropriate health promotion/maintenance and screening history
Immunization history

Review of Systems (ROS)

General
Dermatology
HEENT
Neck
Pulmonary System
Cardiovascular System (CVS)
Breast
Gastrointestinal (GI) System
Genitourinary (GU) System
Female Genitalia
Musculoskeletal System
Neurological System.
Endocrine
Psychologic
Hematologic/Lymphatic

Physical Examination

Vital Signs

Blood Pressure (BP: Temperature Heart Rate (HR) Respiratory Rate (RR)
Height Weight Body Mass Index (BMI) Pain

General Appearance
Dermatology
HEENT
Neck
Pulmonary System
Cardiovascular System (CVS)
Breast
Gastrointestinal (GI) System
Genitourinary (GU) System
Female Genitalia
Musculoskeletal System
Neurological System.
Endocrine
Psychologic
Hematologic/Lymphatic

Significant Data/Contributing Dx/Labs/Misc

Assessment

Differential Diagnoses (3 minimum)
Primary Diagnoses

Plan (For each primary diagnosis, include laboratory/diagnostic tests, therapeutic/pharmacological therapy, referrals, and follow-up ordered and patient education done for this visit)
Diagnoses
Laboratory/Diagnostic Studies
Therapeutic (Non-pharmacological interventions)
Pharmacological Therapy
Patient Education/Anticipatory Guidance
Referrals
Follow up

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________
Date: _______________

RX ______________________________________

SIG:

Dispense: ___________ Refill: _________________

No Substitution

Signature: ____________________________________________________________

Signature (with appropriate credentials): __________________________________________

References (must use current evidence-based guidelines used to guide the care [Mandatory])

5
Joseph, M. V. (2021). Women’s Health Comprehensive H & P. Copyright ©

D
istinguised

E
xcellent

F
air

P
oor

Includes a direct quote from
patient about

presenting problem
Includes a direct quote from

patient and other
unrelated inform

ation
Includes inform

ation but inform
ation is N

O
T

a
direct quote

Inform
ation is com

pletely m
issing

4 P
oints

3 P
oints

2 P
oints

0 P
oints

B
egins w

ith patient initials, age, race,
ethnicity and gender (5 dem

ographics)
B

egins w
ith 4 of the 5 patient dem

ographics
(patient initials, age, race, ethnicity and gender)

B
egins w

ith 3 or less patient dem
ographics

(patient initials, age, race, ethnicity and gender)
Inform

ation is com
pletely m

issing

2 P
oints

1.5 P
oints

1 P
oints

0 P
oints

Includes the presenting problem
and the 8

dim
ensions of the problem

(O
LD

C
A

R
T

S –
O

nset, Location, D
uration, C

haracter,
A

ggravating factors, R
elieving factors,

T
im

ing and Severity)

Includes the presenting problem
and 7 of the 8

dim
ensions of the problem

(O
LD

C
A

R
T

S –
O

nset, Location, D
uration, C

haracter,
A

ggravating factors, R
elieving factors, T

im
ing

and Severity)

Includes the presenting problem
and 6 of the 8

dim
ensions of the problem

(O
LD

C
A

R
T

S –
O

nset, Location, D
uration, C

haracter,
A

ggravating factors, R
elieving factors, T

im
ing

and Severity)

Inform
ation is com

pletely m
issing

5 P
oints

3 P
oints

2 P
oints

0 P
oints

Includes N
K

A
(including = D

rug,
E

nvironem
ental, Food, H

erbal, and/or Latex
or if allergies are present (reports for each

severity of allergy A
N

D
description of

allergy)

If allergies are present, students lists type D
rug,

environem
tal factor, herbal, food, latex nam

e and
includes severity of allergy O

R
description of

allergy

If allergies are present, students lists only the
type of allergy nam

e
Inform

ation is com
pletely m

issing

2 P
oints

1.5 P
oints

1 P
oints

0 P
oints

Includes a m
inim

um
of 3 assessm

ents for
each body system

and assesses at least 9
body system

s directed to chief com
plaint

A
N

D
uses the w

ords “adm
its” and “denies”

Includes 3 or few
er assessm

ents for each body
system

and assesses 5-8 body system
s directed to

chief com
plaint A

N
D

uses the w
ords “adm

its”
and “denies”

Includes 3 or few
er assessm

ents for each body
system

and assesses less than 5 body system
s

directed to chief com
plaint O

R
student does not

use the w
ords “adm

its” and “denies”

Inform
ation is com

pletely m
issing

12 P
oints

6 P
oints

3 P
oints

0 P
oints

Includes all 8 vital signs, (B
P (w

ith patient
position), H

R
, R

R
, tem

perature (w
ith

Fahrenheit or C
elsius and route of

tem
perature collection), w

eight, height, B
M

I
(or percentiles for pediatric population) and

pain.)

Includes 7 vital signs, (B
P (w

ith patient position),
H

R
, R

R
, tem

perature (w
ith Fahrenheit or C

elsius
and route of tem

perature collection), w
eight,

height, B
M

I (or percentiles for pediatric
population) and pain.)

Includes 6 or less vital signs, (B
P (w

ith patient
position), H

R
, R

R
, tem

perature (w
ith Fahrenheit

or C
elsius and route of tem

perature collection),
w

eight, height, B
M

I (or percentiles for pediatric
population) and pain.)

Inform
ation is com

pletely m
issing

2 P
oints

1.5 P
oints

1 P
oints

0 P
oints

Includes a list of the labs review
ed at the

visit, values of lab results and highlights
abnorm

al values O
R

acknow
ledges no

labs/diagnostic tests w
ere review

ed.

Includes a list of the labs review
ed at the visit,

values of lab results but does not highlight
abnorm

al values.

Includes a list of the labs review
ed at the visit but

does not include the values of lab results or
highlight abnorm

al values.
Inform

ation is com
pletely m

issing

3 P
oints

2 P
oints

1 P
oints

0 P
oints

Includes a list of all of the patient reported
m

edications and the m
edical diagnosis for

the m
edication (including nam

e, dose, route,
frequency)

Includes a list of all of the patient reported
m

edications and the m
edical diagnosis for the

m
edication (including 3 of the 4: nam

e, dose,
m

edications route, frequency)

Includes a list of all of the patient reported
m

edications (including 2 of the 4: nam
e, dose,

route, frequency)
Inform

ation is com
pletely m

issing

Subjective

O
bjective

M
edications

Labs

R
eview

of System
s (R

O
S)

H
istory of the P

resent Illness (H
P

I)

D
em

ographics

C
hief C

om
plaint (R

eason for seeking
health care)

A
llergies

V
ital Signs

4 P
oints

2 P
oints

1 P
oints

0 P
oints

Includes an assessm
ent of at least 5

screening tests
Includes an assessm

ent of at least 4 screening
tests

Includes an assessm
ent of at least 3 screening
tests

Inform
ation is com

pletely m
issing

3 P
oints

2 P
oints

1 P
oints

0 P
oints

Includes (M
ajor/C

hronic, T
raum

a,
H

ospitaliztions), for each m
edical diagnosis,

year of diagnosis and w
hether the diagnosis

is active or current

Includes (M
ajor/C

hronic, T
raum

a,
H

ospitaliztions), for each m
edical diagnosis,

either year of diagnosis O
R

w
hether the diagnosis

is active or current

Includes each m
edical diagnosis but does not

include year of diagnosis or w
hether the

diagnosis is active or current
Inform

ation is com
pletely m

issing

3 P
oints

2 P
oints

1 P
oints

0 P
oints

Includes, for each surgical procedure, the
year of procedure and the indication for the

procedure

Includes, for each surgical procedure, the year of
procedure O

R
indication of the procedure

Includes, for each surgical procedure but not the
year of procedure or indication of the procedure

Inform
ation is com

pletely m
issing

3 P
oints

2 P
oints

1 P
oints

0 P
oints

Includes an assessm
ent of at least 4 fam

ily
m

em
bers regarding, at a m

inim
um

, genetic
disorders, diabetes, heart disease and

cancer.

Includes an assessm
ent of at least 3 fam

ily
m

em
bers regarding, at a m

inim
um

, genetic
disorders, diabetes, heart disease and cancer.

Includes an assessm
ent of at least 2 fam

ily
m

em
bers regarding, at a m

inim
um

, genetic
disorders, diabetes, heart disease and cancer.

Inform
ation is com

pletely m
issing

3 P
oints

2 P
oints

1 P
oints

0 P
oints

Includes all of the follow
ing: tobacco use,

drug use, alcohol use, m
arital status,

em
ploym

ent status, current/previous
occupation, sexual orientation, sexually

active, contraceptive use, and living
situation.

Includes 10 of the 11 follow
ing: tobacco use,

drug use, alcohol use, m
arital status, em

ploym
ent

status, current/previous occupation, sexual
orientation, sexually active, contraceptive use,

and living situation.

Includes 9 or less of the follow
ing: tobacco use,

drug use, alcohol use, m
arital status, em

ploym
ent

status, current/previous occupation, sexual
orientation, sexually active, contraceptive use,

and living situation.

Inform
ation is com

pletely m
issing

3 P
oints

2 P
oints

1 P
oints

0 P
oints

Includes a m
inim

um
of 4 assessm

ents for
each body system

and assesses at least 5
body system

s directed to chief com
plaint

Includes a m
inim

um
of 3 assessm

ents for each
body system

and assesses at least 4 body system
s

directed to chief com
plaint

Includes a m
inim

um
of 2 assessm

ents for each
body system

and assesses at least 4 body system
s

directed to chief com
plaint

Inform
ation is com

pletely m
issing

12 P
oints

6 P
oints

3 P
oints

0 P
oints

Includes a clear outline of the accurate
principal diagnosis A

N
D

lists the rem
aining

diagnoses addressed at the visit (in
descending priority)

Includes a clear outline of the accurate diagnoses
addressed at the visit but does not list the
diagnoses in descending order of priority

Includes an inaccurate diagnosis as the principal
diagnosis

Inform
ation is com

pletely m
issing

5 P
oints

3 P
oints

2 P
oints

0 P
oints

Includes at least 3 differential diagnoses for
the principal diagnosis

Includes 2 differential diagnoses for the principal
diagnosis

Includes 1 differential diagnosis for the principal
diagnosis

Inform
ation is com

pletely m
issing

5 P
oints

3 P
oints

2 P
oints

0 P
oints

D
iagnosis

A
ssessm

ent

P
lan

F
am

ily H
istory

Screenings

P
ast M

edical H
istory

D
ifferential D

iagnosis

Social H
istory

P
ast Surgical H

istory

P
hysical E

xam
ination

Includes a detailed pharm
acologic treatm

ent
plan for each of the diagnoses listed under
“assessm

ent”. T
he plan includes A

LL of
the follow

ing: drug nam
e, dose, route,

frequency, duration and cost as w
ell as

education related to pharm
acologic agent. If

the diagnosis is a chronic problem
, student

includes instructions on currently prescribed
m

edications as above.

Includes a detailed pharm
acologic treatm

ent plan
for each of the diagnoses listed under

“assessm
ent”. T

he plan includes 4 of the
follow

ing 7: the drug nam
e, dose, route,

frequency, duration and cost as w
ell as education

related to pharm
acologic agent. If the diagnosis is

a chronic problem
, student includes instructions

on currently prescribed m
edications as above.

Includes a detailed pharm
acologic treatm

ent plan
for each of the diagnoses listed under

“assessm
ent”. T

he plan includes less than 4 of
the follow

ing: the drug nam
e, dose, route,

frequency, duration and cost as w
ell as education

related to pharm
acologic agent. If the diagnosis

is a chronic problem
, student includes

instructions on currently prescribed m
edications

as above.

Inform
ation is com

pletely m
issing

5 P
oints

3 P
oints

2 P
oints

0 P
oints

Includes appropriate diagnostic/lab testing
100%

of the tim
e O

R
acknow

ledges “no
diagnostic testing clinically required at this

tim
e”

Includes appropriate diagnostic/lab testing 50%

of the tim
e O

R
acknow

ledges “no diagnostic
testing clinically required at this tim

e”

Includes appropriate diagnostic testing less than
50%

of the tim
e.

Inform
ation is com

pletely m
issing

5 P
oints

3 P
oints

2 P
oints

0 P
oints

Includes at least 3 strategies to prom
ote and

develop skills for m
anaging their illness and

at least 3 self-m
anagem

ent m
ethods on how

to incorporate healthy behaviors into their

lives.

Includes at least 2 strategies to prom
ote and

develop skills for m
anaging their illness and at

least 2 self-m
anagem

ent m
ethods on how

to
incorporate healthy behaviors into their lives.

Includes at least 1 strategies to prom
ote and

develop skills for m
anaging their illness and at

least 1 self-m
anagem

ent m
ethods on how

to
incorporate healthy behaviors into their lives.

Inform
ation is com

pletely m
issing

5 P
oints

3 P
oints

2 P
oints

0 P
oints

Includes at least 3 prim
ary prevention

strategies (related to age/condition (i.e.
im

m
unizations, pediatric and pre-natal

m
ilestone anticipatory guidance)) and at

least 2 secondary prevention strategies
(related to age/condition (i.e. screening))

Includes at least 2 prim
ary prevention strategies

(related to age/condition (i.e. im
m

unizations,
pediatric and pre-natal m

ilestone anticipatory
guidance)) and at least 2 secondary prevention

strategies (related to age/condition (i.e.
screening))

Includes at least 1 prim
ary prevention strategies

(related to age/condition (i.e. im
m

unizations,
pediatric and pre-natal m

ilestone anticipatory
guidance)) and at least 1 secondary prevention

strategies (related to age/condition (i.e.
screening))

Inform
ation is com

pletely m
issing

4 P
oints

2 P
oints

1 P
oints

0 P
oints

Includes recom
m

endation for follow
up,

including tim
e fram

e (i.e. x # of
days/w

eeks/m
onths)

Includes recom
m

endation for follow
up, but does

not include tim
e fram

e (i.e. x # of
days/w

eeks/m
onths)

D
oes not include follow

up plan

4 P
oints

2 P
oints

0 P
oints

0 P
oints

H
igh level of A

PA
precision

M
oderate level of A

PA
precision

Incorrect A
PA

style
Inform

ation is com
pletely m

issing

3 P
oints

2 P
oints

1 P
oints

0 P
oints

Free of gram
m

ar and spelling errors
W

riting m
echanics need m

ore precision and
attention to detail

W
riting m

echanics need serious attention

3 P
oints

2 P
oints

0 P
oints

0 P
oints

P
harm

acologic treatm
ent plan

F
ollow

up plan

W
riting

G
ram

m
ar

R
eferences

D
iagnostic/Lab Testing

A
nticipatory G

uidance

E
ducation




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