JEWISH WOMEN'S HEALTHA GUIDE FOR HEALTH PROFESSIONALS

IN MEMORY OF MINDEL BAT R'CHAIM

Information to Provide
AFTER a Gynecological Examination/Procedure

The information that is important in rendering a halachic ruling is summarized in the following list of questions. This form can be printed out as a written report whose completion will minimize the chance of errors in transmission. Click here, for the printable form.

Name of procedure / type of examination: ___________

1. According to the patient, was she niddah prior to the examination / procedure? [ ] yes [ ] no
2. Was she experiencing bleeding prior to the examination/procedure?

[ ] active bleeding
[ ] spotting
[ ] no bleeding

3. Were any lesions seen on the vaginal lining that could bleed? [ ] yes  [ ] no
4. If so, would one expect constant bleeding, intermittent bleeding, or bleeding on touch only?

[ ] constant bleeding
[ ] intermittent bleeding
[ ] bleeding on touch only

5. Were any lesions seen on the cervix that could bleed?  [ ] yes  [ ] no
6. If so, would one expect constant bleeding, intermittent bleeding, or bleeding on touch only?

[ ] constant bleeding
[ ] intermittent bleeding
[ ] bleeding on touch only

7. If there is a need to enter the uterine cavity, what was the diameter of the instrument that entered the cervical canal? __________ mm.
8 Was a tenaculum was used? [ ] yes  [ ] no
9. Could the examination or procedure itself lead to any spotting or bleeding?  [ ] yes  [ ] no
10. If so, what is/are the likely source(s) of the bleeding? [ ] vaginal wall [ ] outside of cervix [ ] cervical canal [ ] uterus
11. For how long was this bleeding expected to last? (For example, the scraping of a Pap smear may be followed by a day or so of spotting.) ______  days

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