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Discipline

: Obstetrics & Gynaecology

Sub Discipline

: Gynaecology

Document Title

: Gynaecology Oncology Clerking Sheet

PATIENT INFORMATION

Height

cm

Weight

kg

Bmi

Marital Status

Duration Of Marriage

Para

Lcb

Year(s)

Occupation

REFERRAL

Referral

Outgoing Referrals

Referral Reason

MENSTRUAL HISTORY

LMP

Menopause For

Year(s)

Cycle Day

PATIENT HISTORY

Brief History (Chronology Of Events)

Previous Other Cancers

Previous Other Cancers Method

Please Update Method

Medical Problems

Medical Problems Method

Please Update Method

Surgical History

Surgical History Method

Please Update Method

Previous Surgical Finding

Allergies And Alert

Family History Of Cancer

YesNo

Comments

Other History

OCPs

Aspirin

Anticoagulant

Digoxin

Traditional Medication

Others, specify

PREVIOUS INVESTIGATION

Laboratory

Pap Smear

Please Update Method

Pipelle / Hysteroscopy DD&C (For Uterine Cancer)

Please Update Method

Biopsy (For cervical cancer / vaginal / vulvar cancer)

Please Update Method

For Suspected Ovarian Cancer Patients

Please Update Method

Radiology

Ultrasound Date

Place

Findings

Mass

Common Textbox

Ascites

Common Textbox

Hydronephrosis

Common Textbox

Pleural Effusion

Common Textbox

Liver

Common Textbox

Others, specify

Common Textbox

Ct Scan Date

Place

Findings

Mass

Ascites

Hydronephrosis

Pleural Effusion

Metastases to Liver, lungs, nodes

DVT

MRI Date

Place

Findings

Ascites

Common Textbox

PET Scan Date

Place

Findings

Other Procedures

Pleural Drainage

Ascites drainage

Stenting

Interventional Biopsy

Other Biopsy

SYMPTOMS

Symptoms

Abnormal PV bleed

Abdominal Distention

Abdominal Pain

Post coital bleed

Intermenstrual bleed

Dyspareunia

Dysmenorrhea

Haematuria

PR bleed

SOB

LOA

Low

Others, specify

GENERAL EXAMINATION

Vital Signs & Other Observations

General Condition and Examination

Cachexia

Dyspnoea

Pallor

Jaundice

Enlarged Nodes

Clubbing

Pedal Edema

Varicose vein

System Examination

Abdominal

Common Textbox

Abdominal

Perineum Ultrasound

DIAGNOSIS

Diagnosis

Problem List

MANAGEMENT

Orders

Plan

SIGNATURES

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