Following are items to consider for inclusion as part of a routine female health examination or well-woman visit. This is not intended as an all-inclusive list. Some items may vary depending on the woman’s age, health status, and particular risk factors. Medical history and review of systems may also be indicated. Age and risk-status guidelines for preventive services are available from a variety of sources and authorities.∗ • Last normal menstrual period • Menopause—age achieved, symptoms • Obstetric history—number of pregnancies, term pregnancies, preterm pregnancies, abortions/miscarriages, living children (GTPAL) • Contraceptive measures and history • Breast lumps, discharge, pain, skin changes • Unusual vaginal bleeding or discharge • Abdominal or pelvic pain or bloating • Cardiovascular—smoking, hypertension, diet, body mass index (BMI), exercise, family history • Cancer—personal/family history of breast, ovarian, or colon cancer; history of sun exposure • Infection—sexually transmitted infection (STI) exposure; tuberculosis exposure; hepatitis vaccine or exposure; tetanus/flu immunization • Metabolic—calcium supplement, family/personal history of osteoporosis; exercise; personal/family history of diabetes mellitus; hearing impairment in older adults • Injury—alcohol, seat belts, guns, family/partner violence • Mental health—depression: vegetative symptoms (eating, sleeping, concentration, energy, social interaction)
The Healthy Female Evaluation
History
History of Present Illness
Risk Assessment
Health Habits
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