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Discipline

: Obstetrics & Gynaecology

Sub Discipline

: Obstetrics And Gynaecology

Document Title

: Surgery Clerking Note

HISTORY

Chief Complaint And Duration

Urology

Erectile Dysfunction Symptoms

Erection problems

History Of Presenting Illness [Hopi]

PAST HISTORY

Medical History

Medical History
Diabetes Mellitus
Hypertension
Ischemic Heart Disease (IHD)
Asthma
COAD
Arthritis
Others, specify

Infectious Diseases History

Infectious Diseases History
Hepatitis B
Hepatitis C
HIV
Tuberculosis
Others, specify

Surgical History

Obstetric History

Age Of Menarche

LMP

Last Child Birth (Lcb)

Estimated Years

Age Of Menopause

Antenatal History

Current Medication

Alternate/Traditional Medication

Allergies And Alerts

Allergies And Alert

Adverse Reactions (Non-Allergic )

Personal History

Marital Status

Occupation

Habits

Smoking

Alcohol

Substance Abuse
YesNo
Age Of First Use (Excluding Tobacco)

Sexual History/ Orientation

Immunization

Comment

Family History

Inheritable Diseases

Malignancy

Others, Specify

PHYSICAL EXAMINATION

General
General Condition
Vital Signs
Pallor
Jaundice
Oedema
Head
Neck
Chest
[+] Breast
Breast Laterality
RightLeftBoth
Respiratory System
Cardiovascular System
Arterial Pulsation
Please Update Method
Abdomen
Genitalia
Lymph Nodes
Central Nervous System (CNS)
Musculoskeletal System
Injuries / Burns
Percentage Of Burns
%
Summary

PROBLEM LIST

Problem List

DIAGNOSIS

Diagnosis
Concurrent Illnesses
Co-Morbidities

MANAGEMENT

Plan
Orders
Referral
Outgoing Referrals

SIGNATURES

Notes Component

HISTORY

PAST HISTORY

PHYSICAL EXAMINATION

PROBLEM LIST

DIAGNOSIS

MANAGEMENT

SIGNATURES

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