Text  Description automatically generated with medium confidence

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


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



Past Surgical History

Family Medical History

Social History

Living condition

Marital status




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)