Nome Completo:____________________________________________________________

Data de Nascimento:_________________ Idade: _________

Sexo:___________________________

Motivo da consulta: _______________________________________

Queixa principal

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História da doença atual

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Antecedentes familiares

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Antecedentes pessoais

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Atividade Física

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LSDA

Cabeça e pescoço

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Mamas

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Cárdio-respiratório

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Gastrointestinal

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Urinário

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Genital

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Práticas

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Antecedentes ginecológicos
Pubarca

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Telarca

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Menarca

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Ciclos

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Dismenorreia

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Tensão pré-menstrual

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DUM

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Cirurgia Prévia

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Orgasmo

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Dispareunia

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Frequência

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Sangramento ao coito

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Antecedentes obstétricos

Gestações

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Paridade

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Puerpério

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Amamentação

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Exame físico geral

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Exame ginecológico

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Trato Genital
Pilificação e trofismo

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Clitóris

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Grandes lábios e vestíbulo

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Vagina especular e toque

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Colo especular e toque

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Toque vaginal: útero

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Toque vaginal: anexos e ligamentos

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Achados relevantes

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Hipótese diagnóstica

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Conduta

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