Gynecologic Surgical History

Identifying Data. Age, gravida (number of pregnancies), para (number of deliveries).

Chief Compliant. Reason given by patient for seeking surgical care.

History of Present Illness (HPI). Describe the course of the patient's illness, including when it began, character of the symptoms; pain onset (gradual or rapid), character of pain (constant, intermittent, cramping, radiating); other factors associated with pain (urination, eating, strenuous activities); aggravating or relieving factors. Other related diseases; past diagnostic testing. Obstetrical History. Past pregnancies, durations and outcomes, preterm deliveries, operative deliveries. Gynecologic History: Last menstrual period, length of regular cycle.

Past Medical History (PMH). Past medical problems, previous surgeries, hospitalizations, diabetes, hypertension, asthma, heart disease.

Medications. Cardiac medications, oral contraceptives, estrogen.

Allergies. Penicillin, codeine. Family History. Medical problems in relatives. Social History. Alcohol, smoking, drug usage, occupation.

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