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Medical History Form
Personal Details
Patient Id
Patient NIC No
First Name
Surname
Date of Birth
Occupation
Marital Status
Married
Single
Years and months Married
Years
Months
Other
Presenting Complaint
Menstrual History
lmp DATE
Age Of Menarche
Age Of Menopause
Cycle Frequency
Normal (24 to 38 days)
Amenorrhoea(absent)
Frequent ( < 24 days)
Infrequent ( >38 days )
Duration Of Flow
Normal (Up to 8 days)
Prolonged(< 8 days)
Details
Regularity
Regular (variations7-9 days)
Irregular (variation ≥ 28-10 days)
Details
Flow volume
Normal
Heavy
Clots
Flooding
Light
Spotting
Intermenstrual bleeding
None
Random
Early cycle
Mid cycle
Late cycle
Unscheduled bleeding on gonadal steroids.
NA
None
Present
Dysmenorrhoea
No
Yes
primary
Secondary
Light
Duration
Gynaecological History
Cervical smear
No
Yes
date
Result
Sexual history
Sexually active
No
Yes
Post coital bleeding
No
Yes
Dyspareunia
No
Yes
Superficial
Deep
Previous STI
No
Yes
Details
Contraception
Contraception Current
Contraception Previous
Medical Treatment
Surgical Treatment
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