Female Seafarer Pre-Sea Gynecological Screening Form
Personal Information
Full Name
Date of Birth
Age
Nationality
Rank/Position
Menstrual History
Age at Menarche
Cycle Length (days)
Duration of Flow (days)
Last Menstrual Period
Characteristics
Regular
Irregular
Painful
Heavy Flow
Obstetric History
Gravida
Para
Abortions
Living Children
Complications (if any)
Gynecological History
Previous Gynecological Surgery
Known Gynecological Conditions
Current Symptoms
Pain
Discharge
Bleeding
Other
Contraceptive Use
Current Method
Previous Methods
Sexual History
Sexually Active
Yes
No
History of Sexually Transmitted Infections
Family History
Cancers (breast, ovarian, etc.)
Genetic Disorders
Physical Examination
General Remarks
Gynecological Examination Findings
Laboratory Investigations
Pap Smear
Other Tests
Physician's Summary and Recommendations
Physician Name
Date
Signature