HISTORY QUIESTIONAIRE  How many days does your period

last?
2. History of Present Illness (HPI)
 Do you experience heavy bleeding,
 What symptoms did you first
very light periods, or painful
notice? (Pain, bloating, palpable
menstruation (dysmenorrhea)?
mass, etc.)
 Date of Last Menstrual Period
 When did you first notice these
(LMP):
symptoms?
 Any recent changes in your
 How did the symptoms progress
menstrual pattern (frequency, flow,
over time? (Gradual, sudden,
pain)?
getting worse, improving?)
5. Obstetric History (if applicable)
 What made you decide to seek
medical attention?  How many times have you been
pregnant? (Gravida)
 Did you take any medications or
home remedies before consulting  How many live births? (Parity)
a doctor?
 Any history of miscarriage,
 Have you had similar symptoms in abortion, or ectopic pregnancy?
the past? (If yes, when and how
 Any complications during
was it managed?)
pregnancy or delivery?
3. Past Medical History
6. Family History
 Have you been diagnosed with any
 Does anyone in your family have a
gynecological problems before?
history of ovarian cancer, breast
(Cysts, myoma, endometriosis,
cancer, or uterine cancer?
PCOS, etc.)
 Any family history of ovarian cysts,
 Have you ever been hospitalized
myoma, or gynecological issues?
for any illness or surgery?
(Especially abdominal or pelvic  Any family members with other
surgeries) cancers? (Colon, stomach, etc.)
 Any chronic illnesses?  Any family history of chronic
(Hypertension, diabetes, thyroid illnesses (hypertension, diabetes)?
problems, etc.)
7. Current Symptoms (Focus on Ovarian
 Any history of cancer (any type) in New Growth)
the past?
 Do you feel a lump or mass in your
4. Menstrual History abdomen?
 Age of first menstruation  Any abdominal or pelvic pain?
(menarche):
 Do you feel bloated most of the
 Are your periods regular? time?
  Any changes in your bowel habits?  Do you drink alcohol? (If yes, how
(Constipation, diarrhea, difficulty often?)
passing stool)
 Are you sexually active?
 Any changes in urination?
 Number of sexual partners (if
(Frequency, urgency, difficulty,
applicable):
pain)
 Any history of sexually transmitted
 Any abnormal vaginal bleeding or
infections (STIs)?
discharge?
 Contraceptive use (pills,
 Any sudden weight loss or
injectables, implants)? For how
unexplained weight gain?
long?
 Do you feel full even after eating
10. Previous Consultations and Diagnostic
small amounts?
Workups
8. Environmental History
 Have you consulted any doctor
 Where do you live? (Urban/rural, about this before?
near factories, farms, or industrial
 Have you undergone any tests for
areas)
this condition? (Ultrasound, CT
 What is your occupation? (Do you scan, MRI, blood tests)
work with chemicals, radiation, or
 Were you given any initial
toxins?)
diagnosis or treatment?
 Are you exposed to secondhand
Optional - If Patient Already Has
smoke at home or work?
Diagnosis from Doctor
 Do you use talcum powder on your
 When were you diagnosed with
genital area?
ovarian new growth?
 Any exposure to pesticides,
 What type of new growth (benign
chemicals, or industrial materials?
cyst, malignant tumor) if known?
 Source of drinking water (tap, well,
 Any medications prescribed?
bottled)?
 Any procedures done (biopsy,
 Any use of herbal medicines or
surgery, aspiration)?
supplements for reproductive
health?
 Is your home well-ventilated?
(Especially kitchen areas where
you cook)
9. Social History
 Do you smoke? (If yes, how long
and how much per day?)
For genogram o Breast cancer
1. Are both of your parents still o Colon or other cancers?
alive? If not, what was the cause of
III. Patient’s Children (If applicable)
death?
9. How many children do you have?
2. Do your parents have any
illnesses? 10. Any reproductive health concerns
(Focus on cancers — ovarian, in your daughters (if any)?
breast, uterine, colon, prostate,
11. Any health conditions diagnosed in
plus common illnesses like
your children?
diabetes or hypertension)
IV. Focused Cancer History (for Pattern
3. Do you have siblings? How many?
Detection)
4. Do any of your siblings have any
12. Has anyone in your family ever
illnesses, particularly reproductive
undergone genetic testing for
issues, cysts, or cancers?
BRCA1/BRCA2 mutations or other
5. Have any of your siblings passed cancer genes?
away? If yes, what was the cause?
13. Have any family members had
II. Extended Family (Grandparents & multiple cancers (like breast and
Aunts/Uncles) ovarian)?
6. Did your maternal grandmother
(mother's mother) or paternal
grandmother (father's mother)
ever have:
o Ovarian cancer
o Breast cancer
o Uterine cancer
o Any other cancer?
7. What about your maternal and
paternal grandfathers — any
history of:
o Prostate cancer
o Colon cancer
o Other cancers?
8. Do you know if any aunts or uncles
(on both sides) had:
o Ovarian cysts or tumors
(History of Present Illness)  Malakas po ba o mahina ang
pagdurugo? Masakit po ba?
 Ano po yung unang naramdaman
niyo? (Halimbawa: pananakit ng  Kailan po ang huling regla niyo?
tiyan, pamamaga, matigas na bukol
 May napansin po ba kayong
sa tiyan, etc.)
pagbabago sa regla niyo nitong
 Kailan niyo po unang naramdaman mga huling buwan?
ito?
(Obstetric History)
 Unti-unti po bang lumala o
 Ilang beses na po kayong nabuntis?
biglaan?
(G)
 Ano po ang nagtulak sa inyo para
 Ilang anak na po ang naipanganak
magpatingin sa doktor?
niyo ng buhay? (P)
 May ininom po ba kayong gamot o
 May nakunan po ba kayo o
herbal bago magpatingin?
napaanak ng wala sa oras?
 Dati na po bang may ganitong
 May naging problema po ba kayo
sintomas kayo?
nung buntis o nanganganak kayo?
 Nag pacheck up?( ask if anong
(Family History)
result)
 May kamag-anak po ba kayong
(Past Medical History)
nagkaroon ng sakit sa matris,
obaryo, o suso? (Kanino po at ano
pong sakit?)
 May dati na po ba kayong naging
sakit sa matris o obaryo? (Tulad ng  May kamag-anak po ba kayong
cyst, myoma, PCOS, endometriosis) may kanser? Anong klaseng kanser
po?
 Na-ospital na po ba kayo noon?
Para sa anong sakit?  May lahi po ba kayo ng
altapresyon, diabetes, o iba pang
 May iba pa po ba kayong sakit
sakit?
ngayon? (Halimbawa: altapresyon,
diabetes, sakit sa thyroid) (Current Symptoms)
 May dati na po ba kayong kanser?  May nararamdaman po ba kayong
bukol sa tiyan?
(Menstrual History)
 Masakit po ba ang tiyan o puson
 Ilang taon po kayo nung unang
niyo?
nagkaroon ng regla? (Menarche)
 Pakiramdam niyo po ba ay palaging
 Regular po ba ang regla niyo?
busog o bloated?
 Ilang araw po ang tagal ng regla
 Nahihirapan po ba kayong dumumi
niyo?
o parang laging constipated?
  May pagbabago po ba sa pag-ihi  Aktibo po ba kayo sa
niyo? (Madalas, mahapdi, mahirap pakikipagtalik?
lumabas)
 Ilan po ang naging partner niyo?
 May lumalabas po bang kakaibang
 May history po ba kayo ng STD o
discharge sa puwerta?
iba pang impeksyon?
 May bigla po ba kayong pagpayat o
 Gumamit po ba kayo ng pills,
pagtaba?
injectables, implant, o ibang
 May napansin po ba kayong contraceptives? Gaano katagal?
pagbabago sa ganang kumain?
 Hobbies?
(Environment History)
 Usually ginagawa sa bahay
 Saan po kayo nakatira? (Bayan,
 May mga nasasandalan ba siya if
probinsya, tabi ng pabrika, palayan,
may problems
o bukirin?)
(Previous Consultations and Treatments)
 Ano po ang trabaho niyo? May
exposure po ba kayo sa kemikal,  Nakapagpatingin na po ba kayo
radiation, o toxins? dati tungkol sa ganitong
nararamdaman?
 May naninigarilyo po ba sa bahay o
trabaho niyo?  May mga pinagawa na po ba
kayong test? (Ultrasound, CT scan,
 Gumagamit po ba kayo dati ng
biopsy)
talcum powder sa maselang
bahagi?  May sinabi na po bang diagnosis
ang doktor noon?
 May na-expose po ba kayo sa
pesticide o kemikal?  May gamot na po ba kayong
iniinom ngayon?
 Ano po ang iniinom niyong tubig?
(Gripo, balon, mineral)
 Umiinom po ba kayo ng herbal o
supplement para sa kalusugan ng
matris?
 Maaliwalas po ba ang bahay niyo
lalo na sa kusina?
(social history)
 Naninigarilyo po ba kayo? Gaano
katagal at ilang stick kada araw?
 Umiinom po ba kayo ng alak?
Gaano kadalas?