© Name, age and occupation © Abrief statement ofthe general nature and duration of the ‘main complains (ry to use the patient's own words rather than medical terms at this stage) This section should focus on the presenting complaint, e.9. ‘menstrual problems, pain, subfertity, urinary incontinence, etc. The detailed questions relating to each complaint are covered in more detail in the relevant chapters, but there are Certain important aspects of a gynaecological history that should always be enquired about “Menstrual history © Age of menarche Usual duration of each period and length of cycle (usually wwtten as mean numberof days of bleeding ovr usual length of full cle, e.9 5/28) First day of the last period * Patter of bleeding: regular or regular and length of cycle © Amount of blood loss: more or less than usual, number of sanitary towels or tampons used, passage of clots or flooding © Any intermenstrual or post-cottal bleeding © Any pain relating tothe period, its seventy and timing ot ‘onset * Any medication taken during the period (including over-the- counter preparations). © Site of pain, its nature and severity © Anything that aggravates or relieves the pain - specifically enquire about relationship to menstrual cycle and intercourse © Does the pain radiate anywhere or is it associated with bowel or bladder function (menstrual pain often radiates through to the sacral area of he back and down the thighs)? © Amount, colour, odour, presence of blood © Relationship to the menstrual cycle © Any history of sexually transmitted diseases (STDs) or recent tests * Any vaginal dryness (post-menopaus), Cervical sereoning Date of last smear and any previous abnormalities. © The type of contraception used and any problems with it © Establish whether the patient is sexually active and whet! there are any dificuties or pain during intercourse. © Date of last period © Any post-menopausal bleeding © Any menopausal symptoms, This section should include any previous gynaecological treatments or surgery. © Number of children with ages and birth weights, * Any abnormalities with pregnancy, labour or the puerperium © Number of miscariages and gestation at which they occun © Any terminations of pregnancy with record of gestational ‘age and any complications. © Any serious illnesses or operations with dates © Family history. © Appetite, weightloss, weight gain © Bowel function (f urogynaecological complaint, more det ‘may be required) ‘Bladder function (f urogynaecological complaint, more deta may be required) © Enquiry of other systems. Sensitive enquiy should be made about the woman's social situation including details of her occupation, who she lives wi her housing and whether or not she’s ina stable relationship. ‘history regarding smoking and alcohol intake should also be obtained. Any pertinent fami or other relevant socal probien should be briefly discussed. admission and surgery are bein contemplated i's necessary to establish wat support she ha at home, particularly it she is elderly or frail, ‘The history should be summarized in one to two sentences before proceeding to the examination to focus the problem at alert the examiner tothe salient features.