JEWISH WOMEN'S HEALTHA GUIDE FOR HEALTH PROFESSIONALS

IN MEMORY OF MINDEL BAT R'CHAIM

Information to Provide
BEFORE 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. Must the examination or procedure be scheduled at a specific point in the menstrual cycle?
[ ] yes [ ] no

2. If so, at what point in the cycle? __________________

3. If there will be a need to enter the uterine cavity, what is the diameter of the instrument that will enter the cervical canal? _____ mm.

4. Will a tenaculum be used?
[ ] yes [ ] no

5. Could the examination or procedure itself lead to any spotting or bleeding?
[ ] yes [ ] no

6. If so, what is/are the likely source(s) of the bleeding?

[ ] vaginal wall
[ ] outside of cervix
[ ] cervical canal
[ ] uterus

7. For how long is 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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