1. Introduction

2. SOCRATES

3. MGOS

4. Pmhx/Fmhx/Social&Meds:

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Menstrual:

1) Last menstrual peroid

2) Regularity

3) How long does it last for (In days)

4) Amount (how many pads per day)

5) Menarche

6) Other sx: Pain, spotting

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Gynecological:

1. History of gynecological diseases or surgeries

2. OCP use and type

3. Screening: PAP (last time, reason and results), Mammogram (>40yo), BMD (>65yo)

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Obstetrical (GTPAL):

1. Have you ever been pregnant (how many times)

2. How many term/preterm delivieries and mode of delivery

3. Any abortions

4. How many living children?

5. For each delivery: Term/preterm, Mode, Complications (congenital anomalies)

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Sexual Hx:

1. With whom do you live?

2. Sexually active?

3. Hows your relationship with your partner, do you feel safe & supported?

4. How many partners within last 12 months

5. Screened/diagnosed for STD before