A gynecological history entails assessing the female reproductive system. It is often a sensitive subject for some women; thus, the examiner must treat any information provided with sensitivity and respect. The purpose of this paper is to develop a script for building a health history for a well-woman exam and reflect on my experience building the script.
Hello. I am Nurse XX, and I will take you through today’s well-woman appointment. I will ask you a number of questions about your medical and reproductive health history, some of which might be uncomfortable. However, I assure you that your information will be private and confidential and only be shared with your consent. I hope this will make you more comfortable to express your concerns fully.
What is your name?
How old are you?
Which gender do you identify with?
Do you have any major acute or chronic illnesses?
Do you have a history of surgery or major injury?
Have you ever been hospitalized, and what was the reason?
Which medications (prescriptions or OT) or supplements are you currently taking?
Do you have any drug reactions or environmental or food allergies?
When did you last have your Flu and Tetanus vaccination?
At what age did you start having your menses?
What difficulties do you experience when on your menses, like heavy bleeding or very painful cramping? (Park et al., 2020).
For how many days do your menses last?
Do you experience symptoms like mood or physical changes days before your menses?
Which reproductive health conditions, including STIs, have you previously been diagnosed with?
How many times have you been pregnant, and what was the outcome of each pregnancy?
What pregnancy-related condition did you experience during pregnancy?
Are you currently sexually active?
How would you define your sexual preference and interests? (Park et al., 2020).
How many sexual partners do you have?
Do you experience difficulties during intercourse that affect your sexual satisfaction? (Hagey et al., 2020).
Which type of contraceptive are you currently using, and which side effects does it have?
Which contraceptives have you used previously, and why did you discontinue using them? (Hagey et al., 2020).
What environmental or socioeconomic factors affect your access to gynecology services?
When developing the health history script, I identified that a careful and detailed history is essential before examining a patient presenting for a well-woman exam. I also realized that besides having a good general history, the examiner needs to focus on the history of the presenting complaint to customize the examination to identify the appropriate signs and make an accurate diagnosis. Many women often feel anxious or uneasy about the forthcoming patient interview. Thus, it is vital that the examiner establishes initial rapport with the patient and puts her at ease. During a patient interview, I might feel uneasy asking a patient whether she is sexually active and if there are any difficulties or pain during intercourse. Furthermore, I might be uncomfortable asking a woman about her sexual partners, sexual interests and preferences, and if she gets sexually satisfied. I find that asking a woman about her previous pregnancies can be awkward for the patient, especially if she had an abortion, and often would lie about it if she feels ashamed of it.
I found it insightful for the examiner to be conscious of the different attitudes to various women’s health issues in a religious and culturally diverse population. In addition, I identified a better way of approaching sensitive sexual health questions. This includes initiating the conversation with saying that it is part of my routine to ask all my patients about their sexual health, including sexual functioning and satisfaction (O’Laughlin et al., 2021). SDOH that affects women’s access to gynecology health services can be addressed by maximizing referrals to social services to enhance a patient’s abilities to meet their reproductive health needs (Dagher & Linares, 2022). Furthermore, the NP can advocate for policy changes that promote safe and healthy living environments for women.
The examiner taking a woman through a well-woman exam should take a detailed medical history that includes current acute and ch
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