2. Components
of
HistoryTaking
General information
Presenting complaint
History of presenting complaint
Menstrual history
Pelvic pain
Vaginal discharge
Cervical screening
Sexual and contraceptive history
Menopause (if relevant)
Previous gynaecological history
Previous obstetric history
Previous medical history
Systemic inquiry
Family history
Social history
6. Menstrual
History
Age of menarche
Usual duration of each period (eg- 5/28)
Length of cycle
First day of last period
Pattern of bleeding : regular or irregular 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 inter-menstrual or post coital bleeding
Any pain related to period, its severity and time of
onset
Any medication taken during the period
7. Pelvic Pain
Site of pain
Its nature
Severity
On set of pain
Duration or timing
Radiation
Relieving factors
Exacerbating factors
Any associated symptoms
8. Vaginal
Discharge
Amount
Colour
Odour
Presence of blood
Relationship to menstrual cycle
Any history of sexually transmitted disease (STD) or
recent tests
Any vaginal dryness (post menopausal)
13. Previous
Obstetric
History
Number of children and birth weights
Any abnormalities with pregnancy, labour or the
puerperium
Number of miscarriages and gestation at which they
occurred
Any terminations of pregnancy with record of
gestational age and any complications
17. Social History
Social situation
Occupation and its environment
With whom does she live with?
Housing
Relationships
Smoking and alcohol intake
Support at home