Cramps Encounter Form



MENSTRUAL CRAMPS

Encounter Form

Patient Name ________________________________________________________DOB ________________________

Statement of Incident ______________________________________________________________________________

ALLERGIES ____________________Current Medications ______________________________ LMP _____________

Temp _______________ B/P _______________________________ Pulse ______________ Resp _______________

ASSESSMENT:

Yes No Does your pain/cramps begin 1-2 day before or with the onset of your period

Yes No Does your pain continue after your period

Yes No Does your pain radiate to your back/thighs

Yes No Do you have any nausea, vomiting, headache or other muscle cramping

Yes No Is your period more than 1 week late Yes No

Yes No Do you have a history of unprotected sex ___ Tobacco Use

Yes No Is there any possibility of pregnancy ___ Weight Management

Yes No Do you have a history of STD’s ___ Injury Prevention

___ Drinking/Drug use

PHYSICAL EXAMINATION: ___ School Attendance

___ School performance

Yes No Abdominal exam abnormal ___ Physical Activity

Yes No Neuro exam abnormal ___ Sexual Behavior

Yes No CV exam abnormal ___ IZ's current

Yes No ENT exam abnormal

Notes: __________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________

PLAN/TREATMENT:

Yes No Menstrual sheet attached

Yes No Discuss proper diet, especially increased fluid intake

Yes No Review home remedies such as heating pad, warm bath, exercise, and relaxation techniques

Yes No Ibuprofen 600 mg

Yes No Rx Given _________________________________________________________

Discharge Instructions Given Yes No

Return to Class Yes No Adult Parent Notified (Time) __________________ RTC _________________

RN ______________________________________ MD/NP _______________________________________________

FOLLOW UP

DATE __________________________ TIME _______________

NOTES: ________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

PROVIDER ____________________________________________________________

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