1. Do you have persistent or recurrent genital pains before, during or after intercourse
1.1. Yes
1.1.1. Consider Ovarian Cyst/Fibroid/PID/Endometriosis
1.2. No
2. Are you having problem of Vaginal Discharge
2.1. Yes
2.1.1. White
2.1.1.1. Consult Gynaecologist to rule out Infection
2.1.2. Clear & Watery
2.1.2.1. Possibly Physiological
2.1.3. Clear & Stretchy
2.1.3.1. Possibly Ovulation related
2.1.4. Yellow or Green
2.1.4.1. Brown or bloody
2.1.4.1.1. Get a Pap Smear/Consult Gynaecologist
2.1.4.2. Vaginal Infection.Consult Gynaecologist
2.2. No
3. Are you sexually active
3.1. Not applicable
3.2. Yes
3.2.1. How many partners you have
3.2.1.1. Single
3.2.1.2. More than one
3.2.1.3. Don't want to disclose
3.2.2. Do you use any contraceptives
3.2.2.1. Yes
3.2.2.1.1. Which contraceptive do you use
3.2.2.2. No
3.2.2.3. Discontinued
3.2.2.3.1. Reason why you discontinued using Contraceptive
3.2.3. Do you have history of Infertility or IVF
3.2.3.1. Yes
3.2.3.2. No
3.3. No
3.4. Don't want to disclose
4. Have you done your Pap smear test
4.1. Yes
4.1.1. Was you report Normal
4.1.1.1. Yes
4.1.1.2. No
4.1.1.2.1. What was the finding
4.1.2. When you did your last test
4.1.2.1. Month and Year selection
4.1.2.2. Don't remember the date
4.2. No
5. How frequently you go for Urination
5.1. Very frequently
5.1.1. Have you checked your Blood Sugar
5.1.1.1. Yes
5.1.1.1.1. Is your blood sugar normal
5.1.1.2. No
5.1.2. Do you take any medications like Water pills
5.1.2.1. Yes
5.1.2.2. No
5.1.3. Are you able to control urination
5.1.3.1. Yes
5.1.3.2. Yes
5.1.4. Do you see blood in urine
5.1.4.1. Yes
5.1.4.1.1. Is it associated with pains
5.1.4.2. No
5.2. Between 1 to 5 times
5.2.1. Do ypu take any medications like Water pills
5.2.1.1. Yes
5.2.1.1.1. Give Details/Indications
5.2.1.2. No
5.2.2. Are you able to control urination
5.2.2.1. Yes
5.2.2.2. No
5.2.3. Do you see blood in urine
5.2.3.1. Yes
5.2.3.1.1. Is it associated with pains
5.2.3.2. No
5.3. More than 5 times
5.3.1. Do you take any medications like Water pills
5.3.1.1. Yes
5.3.1.1.1. Give Details/Indications
5.3.1.2. No
5.3.2. Are you able to control urination
5.3.2.1. Yes
5.3.2.2. No
5.3.2.2.1. Consider Urge Incontinence
5.3.3. Do you see blood in urine
5.3.3.1. Yes
5.3.3.1.1. Is it associated with pains
5.3.3.2. No
6. Do you face problem of loss of urine after sneezing, coughing or laughing
6.1. Yes
6.1.1. Consider Stress Incontinence , Consult Gynaecologist
6.2. Never
6.3. Never noticed
7. Does your vagina slips out of position
7.1. Yes
7.1.1. Consider Uterine Prolapse , Consult Gynaecologist
7.2. No
8. Are you having excessive Bleeding/Intermenstrual Bleeding?
8.1. How many pads do you change in a day?
8.2. Is there any history of passing clots?
8.3. Is there any pain associated with bleeding?
8.4. How may days do you have bleeding?
8.5. How frequent are your cycles?
8.6. Is there any inter menstrual bleeding/spotting?
8.7. If the answer is yes to any of the above questions,you need a consult with the Gynaecologist for Pelvic exam,Pap smear and further assessment
9. Any personal history of Abnormal Pap Smear Fibroids Endometriosis Infertility Urinary incontinence Genital warts Herpes -genital Syphilis Chlamydia Gonorrhea Pelvic Inflammatory disease Vaginal Infections
10. Contraception History. Do you/ Have you used any of the following? 1. Oral Pills 2. Injectables(Progestins) 3. Intra Uterine Contraceptive Device(IUCD) 4.Mechanical methods 5. Emergency Contraception
11. When you last had menstrual period
11.1. Date selection option
11.1.1. Selected date is in last three months
11.1.1.1. You had pains during menses?
11.1.1.1.1. Yes
11.1.1.1.2. No
11.1.1.2. What is the Frequency of menses
11.1.1.2.1. Irregular
11.1.1.2.2. After every 28 days
11.1.1.2.3. More than 28 days
11.1.1.3. How long you had menses
11.1.1.3.1. Less than 5 days
11.1.1.3.2. More than 5 days
11.1.1.4. How many pads you change in a day
11.1.1.4.1. Once
11.1.1.4.2. Twice
11.1.1.4.3. Thrice
11.1.1.4.4. More than three times
11.1.1.5. Do you have pains during menses
11.1.1.5.1. Yes
11.1.1.5.2. No
11.1.1.6. Do you have history of Premenstrual bleeding
11.1.1.6.1. Yes
11.1.1.6.2. No
11.1.1.7. Do you have history of Inter-menstrual bleeding
11.1.1.7.1. Yes
11.1.1.7.2. No
11.1.1.8. Do you have any associated pains
11.1.1.8.1. Yes
11.1.1.8.2. No
11.1.2. Selected date in beyond three months
11.1.2.1. Are you postmenopausal
11.1.2.1.1. Yes
11.1.2.1.2. No
12. Have you come across bleeding after intercourse
12.1. Not applicable
12.2. Yes
12.2.1. Consult Gynaecologist
12.2.2. Get a Pap Smear Taken
12.3. No
13. Were you pregnant before
13.1. Yes
13.1.1. Yes
13.1.1.1. Give Details
13.1.2. How many times you were pregnant
13.1.2.1. Once
13.1.2.2. Twice
13.1.2.3. Thrice
13.1.2.4. More than three times
13.1.3. How many children you have
13.1.3.1. One
13.1.3.2. Two
13.1.3.3. Three
13.1.3.4. More than three
13.1.4. You had any complications during pregnancy or delivery
13.1.4.1. No
13.2. No
13.3. Not applicable
13.4. Don't want to disclose
13.5. Abortions
13.6. Ectopic Pregnancy
13.6.1. Get a Urine Analysis done
14. Do you go for urination during night time
14.1. Yes
14.1.1. How many time you need to go
14.1.1.1. Less than two times
14.1.1.2. More than 2 times
14.1.1.2.1. Get Your Urine Analysis done to rule out Infection
14.2. No
15. Do you have problem of painful urination
15.1. Yes
15.2. No
16. Are you currently pregnant
16.1. Yes
16.1.1. What is first date of your last menstrual period
16.1.1.1. Calendar selection
16.1.1.1.1. Your expected delivery date is(add 280 days from first date of last menstrual cycle