Carolyn Cross 41 y.o. F 5’3” 155 lb CC: well-woman
evaluation
Carolyn Cross
41 y.o. F
5’3”
155 lb
CC: well-woman evaluation
Which of the following topics may be included in the well-woman evaluation of females age 40
– 64 years?
• Reproductive health
• General medical status and current impact of past medical history
• Psychosocial and occupational concerns
• Fitness and nutrition
• Risk management: disease, lifestyle, habits, environment
• Immunization status
How can I help you today? – wellness visit; risks for breast cancer; mother 63 and 1st cousin mothers
side dx with breast cancer; wants to know if it increases her risk and by how much Do you have any
other symptoms or concerns we should discuss? – physical exam, nothing more
Do you have pain anywhere? If so, where? – no, nothing unusual for me
PMHx
Can you tell me about any current or past medical problems you have had? Any new
medical issues or diagnoses since your last visit? – cousin and mother Do you have a
history of recent or current infectious disease? – no
Have you had chicken pox, mumps, measles, or rheumatic fever? – no Do you
have high blood pressure? – no
Do you have high cholesterol? – no
Have you ever had hormone replacement therapy? – no
Have you had any recent blood or lab tests? What were the results? – no
Any previous medical, surgical or dental procedures? – normal deliveries, tubal ligation, dental procedures,
regular teeth cleanings
Have you had any hospitalizations? – deliveries
Have you had any significant traumatic injuries or accidents? – no What
childhood illnesses have you had? – coughs, colds, tummy aches
Do you have any allergies, such as medications, food, and/or latex, for example? – no Are you
taking any prescription medications? – in chart
Are you taking any OTC medications? – Vitamin E and ibuprofen
When was your last physical? – a year or so ago
Are you immunizations up to date? Yes
Have you had a flu shot? Yes
Have you had a pneumovax injection? – no
Carolyn Cross 41 y.o. F 5’3” 155 lb CC: well-woman evaluation
, Have you had your TDAP? – why do I need to know Have
you recently traveled? Where did you go? – no At what age
did your periods begin? – age 10.5
How regular are your periods? – regular like every 25-26 days with no bleeding between When did your
last period begin? – 2 weeks ago
Do you have breast fullness or tenderness a few days before the start of your period? – yes What other
symptoms do you have with your period? (Abdominal pain, headache, bloating, etc.) – none
How many live births have you had? – 2 children, 2 pregnancies
Were there any complications when you gave birth to your child? – no When
and what were the result of your GYN exam? – around 3 yrs ago Have you
ever had a pap smear? – yes, always normal
Do you perform breast self examination? – yes
Tell me about the health of your grandparents, parents, and children. – mom 63 diagnosed with breast ca,
1st cousin 44 mother side breast ca – both had lumpectomy and receiving radiation; father has HTN and
Hyperlipidemia; no sisters; brothers are healthy
Are there any diseases that run in your family? – now yes
Do you know of any genetic diseases that are found in your family? – no
Social Hx
Where were you born and where did you grow up? – here What is
your ancestry? – Hispanic descent
Where and with whom are you living? – husband and boys Do
your religious or cultural beliefs … ? – no
What is your educational background? – why do I need to know What
is your highest level/grade in school? – why am I asking
What is your native language? How well do you understand English? – understands Within your
list of responsibilities … - whey do I need to know
Tell me about your work. – middle-school learning specialist
Do you drink alcohol? If so, what do you drink and how many drinks per day? – glass of wine with
dinner each night
Do you use any recreational drugs? If so, what? – none
Do you now or have you ever smoked or chewed tobacco? – no
Can you tell me about your diet, what do you normally eat? – tries to provide healthy meals; eats fast food
at least once a week; pizza once a week; traditional Hispanic diet; cookies at night; 1% milk
Do you drink caffeinated beverages or eat chocolate? – no How is
your appetite? Any recent changes? – fine, no changes
Tell me about your daily exercise or sports you play. – housework and gardening, no sports Any new
exercise or activities? – no
On average, how many hours per night do you sleep? – 6-8 hrs Do
you have adequate housing? – yes
Do you have any children? Spouse? Significant other? – husband for 14 yrs, 2 boys, extended family
Carolyn Cross 41 y.o. F 5’3” 155 lb CC: well-woman evaluation
evaluation
Carolyn Cross
41 y.o. F
5’3”
155 lb
CC: well-woman evaluation
Which of the following topics may be included in the well-woman evaluation of females age 40
– 64 years?
• Reproductive health
• General medical status and current impact of past medical history
• Psychosocial and occupational concerns
• Fitness and nutrition
• Risk management: disease, lifestyle, habits, environment
• Immunization status
How can I help you today? – wellness visit; risks for breast cancer; mother 63 and 1st cousin mothers
side dx with breast cancer; wants to know if it increases her risk and by how much Do you have any
other symptoms or concerns we should discuss? – physical exam, nothing more
Do you have pain anywhere? If so, where? – no, nothing unusual for me
PMHx
Can you tell me about any current or past medical problems you have had? Any new
medical issues or diagnoses since your last visit? – cousin and mother Do you have a
history of recent or current infectious disease? – no
Have you had chicken pox, mumps, measles, or rheumatic fever? – no Do you
have high blood pressure? – no
Do you have high cholesterol? – no
Have you ever had hormone replacement therapy? – no
Have you had any recent blood or lab tests? What were the results? – no
Any previous medical, surgical or dental procedures? – normal deliveries, tubal ligation, dental procedures,
regular teeth cleanings
Have you had any hospitalizations? – deliveries
Have you had any significant traumatic injuries or accidents? – no What
childhood illnesses have you had? – coughs, colds, tummy aches
Do you have any allergies, such as medications, food, and/or latex, for example? – no Are you
taking any prescription medications? – in chart
Are you taking any OTC medications? – Vitamin E and ibuprofen
When was your last physical? – a year or so ago
Are you immunizations up to date? Yes
Have you had a flu shot? Yes
Have you had a pneumovax injection? – no
Carolyn Cross 41 y.o. F 5’3” 155 lb CC: well-woman evaluation
, Have you had your TDAP? – why do I need to know Have
you recently traveled? Where did you go? – no At what age
did your periods begin? – age 10.5
How regular are your periods? – regular like every 25-26 days with no bleeding between When did your
last period begin? – 2 weeks ago
Do you have breast fullness or tenderness a few days before the start of your period? – yes What other
symptoms do you have with your period? (Abdominal pain, headache, bloating, etc.) – none
How many live births have you had? – 2 children, 2 pregnancies
Were there any complications when you gave birth to your child? – no When
and what were the result of your GYN exam? – around 3 yrs ago Have you
ever had a pap smear? – yes, always normal
Do you perform breast self examination? – yes
Tell me about the health of your grandparents, parents, and children. – mom 63 diagnosed with breast ca,
1st cousin 44 mother side breast ca – both had lumpectomy and receiving radiation; father has HTN and
Hyperlipidemia; no sisters; brothers are healthy
Are there any diseases that run in your family? – now yes
Do you know of any genetic diseases that are found in your family? – no
Social Hx
Where were you born and where did you grow up? – here What is
your ancestry? – Hispanic descent
Where and with whom are you living? – husband and boys Do
your religious or cultural beliefs … ? – no
What is your educational background? – why do I need to know What
is your highest level/grade in school? – why am I asking
What is your native language? How well do you understand English? – understands Within your
list of responsibilities … - whey do I need to know
Tell me about your work. – middle-school learning specialist
Do you drink alcohol? If so, what do you drink and how many drinks per day? – glass of wine with
dinner each night
Do you use any recreational drugs? If so, what? – none
Do you now or have you ever smoked or chewed tobacco? – no
Can you tell me about your diet, what do you normally eat? – tries to provide healthy meals; eats fast food
at least once a week; pizza once a week; traditional Hispanic diet; cookies at night; 1% milk
Do you drink caffeinated beverages or eat chocolate? – no How is
your appetite? Any recent changes? – fine, no changes
Tell me about your daily exercise or sports you play. – housework and gardening, no sports Any new
exercise or activities? – no
On average, how many hours per night do you sleep? – 6-8 hrs Do
you have adequate housing? – yes
Do you have any children? Spouse? Significant other? – husband for 14 yrs, 2 boys, extended family
Carolyn Cross 41 y.o. F 5’3” 155 lb CC: well-woman evaluation
