GU INFECTION
Date
Name
DOB/Age
Allergies
LMP
S	Duration
Dysuria frequency urgency hematuria incomplete emptying fever ABD pain flank pain pelvic pain
nausea/vomiting dysparenunia	OTHER
VAGINAL/URETHRAL	Discharge discomfort puritus bumps sores blisters	WET MOUNT
O	VITALS	BP
P
T
Weight
Urine PG
UA
A
P
RX
UC
VAG/URETHRAL CULTURE
GC/CHLAMYDIA
HSV
IVP
Partner RX
Back-up contraceptive

GU INFECTION
Date
Name
DOB/Age
Allergies
LMP
S	Duration
Dysuria frequency urgency hematuria incomplete emptying fever ABD pain flank pain pelvic pain
nausea/vomiting dysparenunia	OTHER
VAGINAL/URETHRAL	Discharge discomfort puritus bumps sores blisters	WET MOUNT
O	VITALS	BP
P
T
Weight
Urine PG
UA
A
P
RX
UC
VAG/URETHRAL CULTURE
GC/CHLAMYDIA
HSV
IVP
Partner RX
Back-up contraceptive

2002-11-18

Microsoft Corporation