Chief complaint:

Character
Onset
Progression
Location
Intensity/Intermitent
Alleviators
Aggravators
Associated symptoms
Refered
Pain anywhere else
Fx impairment

Everyone:
PMHx
Allergies
Medications
Hosp
ROS
FHx
Occupation
Social
Sexual
Weight changes
Travel
Fever

Violence:
Safe at home?
Alcohol? Afraid of husband?
Family knows about it?
Emergency plan?
Guns?
U
Any children?
Relationship with husband?
Drugs? Depression?

Women in reproductive age:

LMP
Menarche
Period
Regular
Tampons
Vaginal itch/discharge
Cramps
Spotting
Para
Abortions
PAP

Any liq. discharge:

Content
Amount
Blood
Color
Oddor

Depression:
Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor
Suicidal ideation

aid of husband?
s about it?

with husband?

Children:
Complications during pregnancy or childbirth
Daycare
Vaccines
Seizures
Milestones
Lethargic
Ear pulling