ENSURE PRIVACY and discuss confidentiality
Personal Details
- Name
- Age
- Consent
Presenting Complaint
- Symptomatic / Asymptomatic
- Consider: Onset, duration, recurrence, precipitating/relieving factors, previous investigations and treatments
- Common symptoms in males: urethral discharge, urethral irritation, dysuria, frequency, testicular/scrotal swelling/pain, genital ulcer/blister/lump, rash, rectal pain/discharge/bleeding
- Common symptoms in females: vaginal discharge, lower abdominal pain, dyspareunia, dysuria, dysmenorrhoea, ulcer/blister/lump, rash, itching/soreness
Sexual history in the last 3 months
- Last sexual intercourse: – when?
- female/male partner?
- casual/regular partner?
- together how long?
- origin of partner?
- type of sex: oral/vaginal/anal/fisting/rimming/sex toys
- condom used?
- Same for previous partner before last
- Any other partners in last 3 months? How many?
- Any other risk factors e.g sex worker / IVDU
- Any non-consensual sex
STI History
- Date of any previous STI diagnosis and treatment
- Last ST test
Menstrual History
- First day of last menstrual period
- Regularity of normal cycle
- Cycle Length
Contraceptive history
- Current contraception
- Previous contraceptives
Medical History
- Pap smear test: when, where, result, compliance
- Current or past illnesses
- Hospital admissions
- Any previous blood transfusions
- Diabetes, Migraine with/without aura, HTN, CHD/stroke, thrombosis/PE, breast cancer, liver disease, epilepsy, HIV, porphyria
Surgical History
- Past surgeries
Gynaecological History
- Current/past gynaecological problems
Obstetric History
- Gravidity and parity
- Date and outcome of last pregnancy
- Mode of delivery
- Complications
- Breastfeeding?
Drug History
- Current medication – over the counter/herbal and prescribed
- Recent antibiotics? (may affect culture results)
- Recreational drugs, IVDU?
- Allergies
Family History
- Medical complaints: CHD/stroke, DVT/PE, Breast cancer
Social History
- Smoking and alcohol
- Occupation
- Country originates from
Sexual Health Examination
ENSURE PRIVACY and OFFER CHAPERONE (document in notes)
General Examination
e.g skin/ throat/ joints/ abdomen etc
Genital Examination:
- Females: - inguinal lymph nodes enlarged?
- inspect: vulva, vagina
- vaginal discharge: normal/abnormal
odour?
white/creamy/brown/grey/green/yellow?
consistency: watery/thick/curdy/frothy
- speculum: cervix: normal/abnormal
cervical discharge: normal/abnormal
- bimanual examination: uterus size and position, adnexal tenderness, adnexal mass
- Males: - inguinal lymph nodes enlarged?
- inspect: penis, scrotum, testes
- urethral discharge: yes/no?
clear/milky/yellow/green