Women’s Clinic Examination Form

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Womens Clinic Examination

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Women’s Clinic Examination
Chief Complaint:
¨ Here for breast examination and counseling.
¨ Here for osteoporosis screening and counseling.
¨ Additional question(s) or concern(s): _____________________________________________________________________________________
¨ Old chart not available


Osteoporosis Risk Yes No Postmenopausal HRT > 3 mo. hx (ever) of anti-coagulant, steroid, or anti-seizure medication Hyperparathyroidism * Chronic disease such as dementia, gastric surgery, hemiparesis, Parkinsons, vertigo, blindness, rheumatoid arthritis * Hx low-trauma Fx * Hx in 1st degree relative * Alcohol abuse * Smoker * Physical inactivity * Low weight * Inadequate sunlight exposure or low dietary calcium
? Medication list reviewed; no changes
? Medication list reviewed and updated

Health Maintenance:
Last mammogram ____/____/____
Last clinical breast exam ____/____/____
Last occult blood ____/____/____
Last Osteoporosis screening ____/____/____ (Must be 23 months for Medicare reimb.)

Physical Exam:

Vital Signs: Weight: ______ lbs. Blood Pressure: __________ Temp_______________

Examination of Breasts:

No Yes Comments:





?No significant clinical findings Breast Implants Mastectomy Distinct palpable mass or thickening Skin dimpling/reddening Bloody nipple discharge Nipple discharge that is unilateral, spontaneous or localized to one duct Skin retraction or scaliness around nipple Inverted nipple (recent occurrence/onset) in a woman who is not lactating New onset of pain in elderly atrophic breast Impression:
Recommend osteoporosis screening ?Yes ?No
Recommend Vitamin D (600 IU/d) and Calcium (1000 mg/d) supplement ?Yes ?No
Screening Mammogram needed ?Yes ?No
Diagnostic Mammogram needed ?Yes ?No
Specialty referral given: ?Yes ?No – to which specialty ______________________________
Occult blood “home test” given ?Yes ?No
Pneumococcal vaccination ordered (0.5cc IM) ?Yes ?No
Influenza vaccination ordered (0.5cc IM) ?Yes ?No

Follow-up: ______________________________________________________________________________

Educational material given on breast care? ?Yes ?No
Educational material given on bone health? ?Yes ?No

Signature: ___________________________________ ?MD/DO ?NP ?PA Date: ____/____/____