Doña Remedios Trinidad Romualdez Medical Foundation

COLLEGE of NURSING

RLE Worksheet on Health Assessment

GENITOURINARY SYSTEM & RECTUM and PROSTATE

Name:________________________________________________________ Section:_______________

FEMALE GENITAL EXAMINATION:

A. Conduct an Interview with an adult female. Use the write-up worksheet below for the
documentation:

Name of patient: Optional

Age: Sex:
Date and Time of interview:

I. Health history

1. Menstrual history

Age at first period?_____________________________________

Date of your last menstrual period?_______________________

How often are your periods? Cycle? _______________________

How many days does your period last?_____________________

Usual amount of flow: (Circle) light medium heavy

Any clotting? ________________ Any pain or cramps? ________________ Any spotting?

Any associated symptoms: Bloating? ___________ Breast tenderness? ___________ Moodiness?

2. Obstetric history

Have you ever been pregnant? ____________________

How many times?_____________________________

Any miscarriages or abortions?__________________

Describe pregnancy(ies):_______________________

Duration: ___________________________________ Any complications?___________

Labour and delivery? __________________________ Baby’s sex:_____________

Birth weight _________________________________ Condition:_____________

Pregnant now? _______________________________ Symptoms?

3. Menopause

Periods slowed down or stopped? _________________ Any associated symptoms?

Any management? ____________________________ Hormone replacement?

How much? _________________________________ How is it working?

Any side-effects? ______________________________ Using other therapies?

How do you feel about menopause?_________________

4. Self-care practices

Pap smear frequency? __________________________

Immunised against human papillomavirus?:_________________

5. Any problems with urinating? ___________________ Pain or burning?______________

Frequency? __________________________________ Urgency?

6. Any unusual vaginal discharge? __________________ Increased amount?_____________

Character or colour: (Circle) white yellow-green grey curd-like foul smelling?

When did this begin? __________________________

Associated with vaginal itching?__________________

Rash? ______________________

Pain with intercourse? __________________

Taking any medications? _________________

Family history of diabetes? _______________

7. Past history

Any other problems in the genital area?_______________

Sores or lesions? ______________________________ At present?____________

In the past? __________________________________ Treatment?_____________

Any abdominal pain?_______________________

Any past surgery on uterus? _____________________ Ovaries?_______________

Vagina?________________________

8. Sexual activity

Any questions about your sexual relationship?________________________

In a relationship involving sex now?___________________________

Are aspects of sex satisfactory to you and your partner?____________________

Communicate about sex?__________________________

More than one sexual partner? ___________________ Explain________________

9. Contraceptive use

Planning a pregnancy? _________________________ Avoiding pregnancy?_______________

Use a contraceptive? __________________________ Which method?_____________

Is this satisfactory? ____________________________ Do you have any questions?

Have you ever had any problems becoming pregnant?__________________

10. Sexually transmitted infection (STI) contact

Any sexual contact with partner who had an STI?__________________

When?_ _____________________________________ How was this

treated?__________________________
 Document normal findings of the female genitourinary system

Physical examination

A. Inspect external genitalia

Skin colour and characteristics

Hair distribution

Labia majora symmetry

Clitoris

Labia minora

Urethral opening

Vaginal opening

Perineum

Anus
MALE GENITAL EXAMINATION:

A. Conduct an Interview with an adult male. Use the write-up worksheet below for the
documentation:

Name of patient: Optional

Age: Sex:
Date and Time of interview:

Health history

1. Any urinary frequency? _________________ Urgency? _________________ Nocturia?

2. Any pain or burning with urinating?___________________________

3. Any trouble starting urine stream?___________________________

4. Urine: _________________ Colour? _________________ Cloudy?

Foul-smelling?_________________________________ Red-tinged or blood-stained?

5. Any pain or sores on penis?__________________________

6. Any discharge? ________________________________ How much?

Discharge colour? _________________ Cloudy? _________________ Foul-smelling?__________________

7. Any lump in testicles or scrotum?______________________________

8. Do you perform testicular self-exam?_______________ Any Lumps or swelling?___________________

Bulge or swollen scrotum?_______________________________

Dragging?_ ___________________________________ Hernia?____________________

9. Family history of prostate cancer?________________________________

10. PSA or DRE? _________________________________ When?____________________

11. Sexual activity: In relationship now?_________________________________

Use a contraceptive? ___________________________ Which one?_____________________

How many partners in last 6 months?__________________________

Problems with erection?____________________________________

Sexual preference?________________________________________

12. STI contact?__________________________________________

Ever been diagnosed with an STI? __________________ When?__________________________

Treatment?________________________________
 B. Document normal examination findings on the physical examination of the male genitalia

Physical examination

A. Inspect penis

Skin condition ________________________________ Lesions?

Glans ___________________ Foreskin retractable? ____________ Smegma?_ __________________

Urethral meatus:_____________________

Pubic hair distribution:___________________-

B. Inspect the scrotum

Skin condition ________________________________ Lesions?________________

Size_____________________________

Swelling___________________________

Symmetry________________________