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Obtain a medical history in a reproductive-aged woman

Learner Task: Take a pertinent history in a reproductive woman.
Educator Script: Provide the following pertinent patient history of a reproductive-aged woman with pelvic pain as asked by the learner.

  • HPI: Gravida 0, LMP 6 weeks ago
  • P GYN Hx: Menarche at 12 years old, menstrual cycles q28-30 days lasting 4 days, moderate dysmenorrhea, no dyspareunia, coitarche at 16 year old, 2 lifetime male partners, treated for chlamydia 1 year ago, using condoms inconsistently for contraception, has never had a Pap smear.
  • PMH: None
  • Meds: None
  • Allergies: No drug allergies
  • PSH: Tonsillectomy and adenoidectomy
  • Social History: She is in her senior year of high school, makes A’s and B’s in school. She is heterosexual and has had a boyfriend for a little over a year, they use condoms some of the time. She is in the school band, smokes occasionally, has tried alcohol, and denies drugs.
  • Review of systems: Complains of loss of appetite today, nausea x 2 weeks, denies the following: vomiting, constipation, increased urinary frequency, vaginal discharge or odor, personal history of bleeding disorders, breast discharge or tenderness, headaches, sob, dizziness, chest pain, and fever.

Educator Checklist: History Taking
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.

Included =1 Not Included =0
Student introduced her/himself appropriately (first name, last name, medical student)
Student addressed patient as per patient preference
Student clarified purpose of visit
Student washed hands correctly (before touching patient)
Obtains accurate gynecologic history and sexual history
Obtains accurate obstetrics history
Obtains accurate review of systems for chief complaint  


Obtains accurate past medical history
Obtains accurate surgical history
Obtains accurate medication use, asks about over the counter and herbal supplements
Obtains accurate allergy history
Obtains accurate family history
Obtains accurate social history including smoking, alcohol use, drug use