Gynecologic

Explains task, assures confidentiality, obtains consent

 * Hello my name is [Medical Student] and I'm a first year medical student at [Medical School].
 * Can I please get your full name and age please?
 * Miss. Doe, today my attending physician has asked me to take a history; I will be asking you a few question about your health, is that okay?
 * I just want to remind you that anything we discuss is confidential.
 * Is there anything you need before we get started?

Begins with open ended questions and transitions

 * Miss Doe, what brings you in today?
 * Just to make sure I heard you correctly...*summarize*
 * Miss Doe, I'd like to ask you a few questions about your menstruation.

Asks about age menarche, days of menstrual blood flow, cycle

 * How old were you when you first had your period?
 * How long is your menstruation cycle?
 * How long do your periods usually last?
 * How many pads or tampons do you use per day?
 * What color is the flow?

Asks about regularity in menses and LMP

 * Have you had any recent periods that were early or late?
 * Have you missed any periods in the past few months?


 * When was your last menstrual period?
 * Do you have any bleeding between your periods?
 * Is your menstruation painful?

GP (term, preterm, abortions and living children)

 * GP
 * G = Gavidia = total number of pregnancies
 * P = Para = outcomes of the pregnancies
 * Have you ever been pregnant?
 * How many times?
 * How many living children do you have?
 * Did you have any difficulties during pregnancy?
 * Have you ever had a miscarriage or an abortion?
 * How many times?
 * I get a better picture of what's going on, I'm going to be asking you some personal questions; is that okay?

Asks about dyspareunia, dysmenorrhea

 * Miss Doe, are you sexually active right now?
 * How many sexual partners do you have?
 * What type of sex do you have?
 * Vaginal, anal, oral sex.
 * Do you use any contraception during sex?
 * Are you trying to become pregnant or prevent pregnancy?
 * Do you have a history of sexually transmitted infection?
 * Do you have any pain during intercourse?

Asks about urinary incontinence if the patient has had children

 * Do you have any trouble controlling your bladder?

Asks for dates and results of last cervical smear test & contraception use

 * When was your last cervical smear test?
 * What was the result?

Asks about vaginal discharge quantity, color, odor

 * Have you noticed any vaginal discharge?
 * How much discharge?
 * What color is it?
 * Is there an odor?
 * What does the odor smell like?

Summary presentation and communication skills

 * We have a 30 year white female that presented abdominal pain. Her menstration and family history is unremarkable. The patent states that she's sexually active with 3 partners and has a history of STI.