1. Opening the consultation
Wash your hands |
Introduce yourself (full name) and role |
Confirm patient's name and date of birth |
Establish confidentiality |
Confidentiality: "Anything said here today will be confidential unless I feel another person or yourself is at immediate risk, in which case I would need to share some information. I appreciate some questions may be difficult to answer, if there is anything you don't want to answer right now, we can come back to it another time. Does that sound okay?"
2.1 Presenting Complaint - Female
Vaginal discharge |
Volume, Colour, Consistency, Smell |
Vaginal bleeding |
Nature and pattern of the bleeding, Volume, Colour, Impact on quality of life |
Dyspareunia |
Location, Duration, Nature |
Abdominal and pelvic pain |
SOCRATES |
Vulval skin changes/lesions |
Location, painful/non-painful |
Itching |
Timing of the symptom, episodic vs constant, skin irritants |
2.2 Presenting Complaint - Male
Urethral discharge |
Volume, Colour, Consistency, Smell |
Dysuria |
Pain on passing urine, urinary frequency, haematuria |
Testicular pain or swelling |
SOCRATES |
Penile skin changes/lesions |
Location, painful/non-painful |
Itching |
Timing, episodic or constant, skin irritants |
Penile swelling |
Swelling? Ability to replace foreskin? |
Abdominal or pelvic pain |
SOCRATES |
2.3 Presenting Complaint - Rectal symptoms
Rectal discharge |
Volume, Colour, Consistency |
Rectal pain |
SOCRATES |
Rectal lump |
Anal skin changes/itching/lesions |
Location, painful/non-painful |
3. ICE + Summarising
Ideas |
Concerns |
Expectations |
Summarising |
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4. Systemic enquiry
Fever |
Malaise |
Weight loss |
Rash |
Swelling and tenderness of large joints, conjunctivitis |
5. Menstrual History
Date of last menstrual period (LMP) |
"What date was the first day of your last menstrual period?" |
Cycle length |
"How often do your periods occur?" |
Cycle regularity |
"Are your periods regular and predictable?" |
If late period, offer patient a pregnancy test.
6. Obstetric History
Parity, gravidity and modes of delivery |
Previous history of termination of pregnancy? |
7. Sexual History
Timing |
When was the last time you had sex? |
Sexual Contact |
Type of sex? |
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Did you give or receive anal/oral? |
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Did you feel like you could say no to sex during your encounter? |
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How old is your partner? How did you meet them? |
Relationship |
Male or female partner? |
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Regular or casual partner? |
Contraception |
Did you use contraception? |
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Were there any problems with using contraception? |
Other partners |
Have you had any other partners within the last 3 months? |
STI testing |
When was your last sexual health screen? |
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Have you or any of your partners been diagnosed with an STI? |
7.1 Blood borne virus risk assessment
Have you ever injected any recreational drugs? |
Have you ever used recreational drugs during sex? |
Have you ever paid someone for sex or have been paid for sex? |
Have you ever had a partner known to be HIV positive? |
When was your last blood test for HIV and syphilis? |
Have you been immunised for hep A/B and HPV? |
Are you currently taking any PrEP for HIV? |
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8. Gynaecological + Screening History
Do you have a history of any gynaecological problems? |
What was the date and result of your last cervical screening test? |
Did you receive any treatment? |
Have you been vaccinated against HPV? |
9. Past Medical History
Surgery |
Have you ever had any surgery? |
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Have you ever had any procedures done to your genitals? |
Medical |
Any recent hospital admissions? |
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Any conditions you go to the GP for? |
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If so, what treatments are you on? |
10. Drug History
Do you take any medications? Herbal remedies? Over the counter? |
If so, are you able to take your medications as prescribed? |
Are you allergic to any drugs? |
11. Social History
Smoking |
Type and amount of tobacco |
Alcohol |
Frequency, type and volume |
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Offer support services to assist with reduction if relevant |
Occupation |
What do you do for a living? |
Home |
Who are you currently living with at home? |
Safeguarding |
Do you currently feel safe at home? |
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