Gyna Sheet

---

Menstrual History					Sexual History
Reg C/D Amount Dysm LMP

Medical History		Surgical History		Family History

{foreach $awifep as $single} {/foreach}

(Obst History) p
Sex	Name	Date of D	Age	Mode of D	Type of D	W	L	Obst	CO Method Duration Stopped	Comment
			{$single->wifeage}				wifel == 1} checked {/if}>

{foreach $wifeepc as $single} {/foreach}

EPC							Last
date	Type	W	TTT	Obst	Histopath	Cost	D	A

General		Local
BW		Vulva
BMI		Vagina
Breast		CX
Hirsutism		Other
Thyroid		Other

{foreach $hormonalprofile2 as $single} {/foreach}

Hormonal Profile
	AMH	TSH	PRL	FSH	LH	E2	P4	Other
Date
Result

{foreach $tvs as $single} {/foreach}

TVS
Date
UT
CX
RO
LO
Pelvis

{foreach $hysteroscopy as $single} {/foreach}

Hysteroscopy
Date	PLace	Dil	Introd	CX	Cavity - Fundus	R-Ostium	L-Ostium
Intervention

{foreach $laparoscopy as $single} {/foreach}

Laparoscopy
Date	PLace	UT	RT	LT	RO	LO	Pelvis
Intervention

{foreach $infertilityother as $single} {/foreach}

Other
Name	Date	Details

Lab	Lab Add Show

{assign var="i" value="1"} {foreach $operations as $single} {assign var="i" value=$i+1} {/foreach}

operations
	operation	Date	place	histopath	Cost	notes
{$i}

{foreach $newvisitg as $single} {/foreach}

New Visit
Date	Cycles	LMP	BW	usvsdtv eq 1} checked {/if} >US usvsdtv eq 2} checked {/if} >TVS usvsdtv eq 3} checked {/if} >3D TVS UT OV	Notes
					{$single->noteg}
C/O				Diagnosis	TTT (Button)
					TTT Add Show
{$single->plan}