"Ob/Gyn History and Physical Evaluation Form - University of Alabama"

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OB/GYN HISTORY AND PHYSICAL EVALUATION FORM
Student: __________________________
Signature: _____________________
Date: _________________
Evaluator: _________________________
Signature: _____________________
Please check: GYN____OB____
Circle the components of H&P that are presented and check the box for observed history items. Use the Strengths and Improvements sections for student feedback.
Please return this form to the student.
Circle the Appropriate Number
Strengths:
History (15 items) - Observed
0------1
Chief Complaint
History of Present Illness (4 elements)
0------1------2------3------4
Review of Systems (2 systems)
0------1------2
Medications/Allergies
0------1------2
Family History / Social History / PMH / PSH
0------1------2------3------4
Areas for Improvement:
0------1------2
OB History / GYN History
0------1------2------3------4------5
Physical Exam (5 systems / items) - Observed
Vital signs / General / GI /
GU / Other
Medical Decision Making (5 items)
N/A---0------1------2
Labs / Diagnostic Test
0------1------2------3
Assessment / Differential Diagnosis / Plan
Each student is required to hand in 2 H&P evaluation forms, one OB H&P and one GYN H&P. One should be submitted in week 4 with the mid-clerkship
evaluation. The other one should be submitted by the end of week 7. At least one of these will be an OBSERVED History & Physical.
OB/GYN HISTORY AND PHYSICAL EVALUATION FORM
Student: __________________________
Signature: _____________________
Date: _________________
Evaluator: _________________________
Signature: _____________________
Please check: GYN____OB____
Circle the components of H&P that are presented and check the box for observed history items. Use the Strengths and Improvements sections for student feedback.
Please return this form to the student.
Circle the Appropriate Number
Strengths:
History (15 items) - Observed
0------1
Chief Complaint
History of Present Illness (4 elements)
0------1------2------3------4
Review of Systems (2 systems)
0------1------2
Medications/Allergies
0------1------2
Family History / Social History / PMH / PSH
0------1------2------3------4
Areas for Improvement:
0------1------2
OB History / GYN History
0------1------2------3------4------5
Physical Exam (5 systems / items) - Observed
Vital signs / General / GI /
GU / Other
Medical Decision Making (5 items)
N/A---0------1------2
Labs / Diagnostic Test
0------1------2------3
Assessment / Differential Diagnosis / Plan
Each student is required to hand in 2 H&P evaluation forms, one OB H&P and one GYN H&P. One should be submitted in week 4 with the mid-clerkship
evaluation. The other one should be submitted by the end of week 7. At least one of these will be an OBSERVED History & Physical.