Following are items to consider for inclusion as part of a routine 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. Past medical history (PMH) and review of systems (ROS) may also be appropriate if indicated. Age and risk-status guidelines for preventive services are available from a variety of sources and authorities.*
HISTORY
HISTORY OF PRESENT ILLNESS (HPI)
Age
Last normal menstrual period (LNMP)
Menopause—age achieved, symptoms
Obstetric history—number of pregnancies, term pregnancies, preterm pregnancies, abortions/miscarriages, living children (GTPAL)
Contraceptive measures and history
Sexual history
Breast lumps, discharge, pain, skin changes
Unusual vaginal bleeding or discharge
Abdominal or pelvic pain or bloating
Urinary symptoms
RISK ASSESSMENT
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 violence
Mental health—depression: vegetative symptoms (eating, sleeping, concentration, energy, social interaction)
HEALTH HABITS
Breast self-awareness or self-examination
Pap smear—how often; date of last Pap smear; results, ever an abnormal result?
HPV DNA test—date, results
Mammogram—date, result of last mammogram
Diet—fat, cholesterol, calcium
Exercise—amount, frequency
Smoking/tobacco use
Alcohol/drugs
PHYSICAL EXAMINATION
Vital signs: BP
Height and weight; BMI
Skin—lesions, moles
Lungs
Cardiovascular and peripheral vascular
Breasts—contour, masses, nipple discharge, skin changes
Lymph—regional lymphadenopathy (infraclavicular and supraclavicular, axillary, inguinal)
Abdomen—bowel sounds, masses, organ enlargement, hernias
Pelvic—lesions, discharge; Bartholin glands, urethra, Skene glands; vagina, cervix, adnexa, uterus; rectovaginal septum
Rectal—hemorrhoids, masses, lesions
SCREENING RECOMMENDATIONS
Cardiovascular
Blood pressure—begin at age 18
Lipid profile—begin at age 45
Cancer
Pap smear—begin within 3 years of onset sexual activity or age 21 (whichever comes first) and screening at least every 3 years; frequency depends on age, sexual status, PMH, Pap smear history
HPV DNA test—women older than age 30 years, every 3 years; or if Pap smear shows ASC-US (atypical squamous cell of undetermined significance) in women older than age 20
Mammogram—begin at age 40; earlier if at increased risk; frequency depends on personal and family history, past results
Multiple fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year; or flexible sigmoidoscopy or CT colonography (virtual colonoscopy) every 5 years; or colonoscopy every 10 years—begin at age 50; earlier depending on personal and family history
Infection
STI testing—depending on exposure status; chlamydia screening—age 24 years and younger or age 25 years and older at increased risk
TB skin testing—depending on risk status
Metabolic
BMI for obesity
Fasting plasma glucose—for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg
Bone density—women ages 65 or older; begin at age 60 if at increased risk
Hearing impairment—older adults
Injury
Family violence (see Appendix Special Histories)
Mental health
Alcohol and substance abuse (see Appendix Special Histories)
Depression
* Authorities that produce prevention guidelines include Academy of Family Physicians, American Cancer Society, American College of Obstetricians and Gynecologists, American College of Physicians, American Geriatrics Society, Canadian Task Force on the Periodic Health Examination, National Cancer Institute, and the U.S. Preventive Services Task Force.