REPORTING OF OB-GYNE CASE HISTORY

I. GENERAL DATA
II. CHIEF COMPLAINT
III. HISTORY OF PRESENT ILLNESS (for OB/pregnant patients)
- Include the following at the end of HPI: Last Menstrual Period (LMP), Previous
Menstrual Period (PMP), Age of Gestation (AOG), Estimated Date of
Confinement (EDC)
IV. PRENATAL HISTORY
V. OB-GYNE HISTORY
a. MENSTRUAL HISTORY
i. MENARCHE
ii. SUBSEQUENT MENSES
iii. LMP, PMP (for Gyne/non-pregnant patients)
b. OB SCORE
c. SEXUAL HISTORY
d. GYNECOLOGIC HISTORY
i. Gynecologic Illnesses
ii. Gyne operations
iii. Hormonal Therapy
iv. Family planning
v. Pap smear
VI. PAST MEDICAL HISTORY
VII. FAMILY HISTORY
VIII. SOCIAL AND ENVIRONMENTAL HISTORY
IX. REVIEW OF SYSTEMS
- Included here are the symptoms of different systems not mentioned in the HPI