Taking an OB/GYN history can be awkward as hell, especially when you're a guy who doesn't know what it's like to have female organs or female issues. However, knowing exactly what questions to ask can take you a long way and make you look waaaaaaaay more confident. I break the history into 2 main parts: obstetrics and gynecology (kinda obvious, right).
This part of the history focuses on a woman's pregnancy history and current pregnancy, if applicable.
Parity: The keystone to the obstetric history is the parity, AKA knowing how many times the patient has been pregnant. Instead of an open-ended question, I start with "have you been pregnant," then ask "how many times?" The format for reporting parity is G-TPAL. First, "G" stands for the number of pregnancies. Next are listed four numbers. "T" stands for any child born after 37 weeks. "P" stands for preterm births, AKA any child born before 37 weeks. "A" stands for abortions; this can include elective abortions, spontaneous abortions (occur before 20 weeks), miscarriages (occur after 20 weeks), or ectopic pregnancies. Finally, "L" stands for the number of living children. This number may be larger than "G," if the patient has had a set of twins (G=1 but L=2). Sometimes this is all simplified as "GP," which is the number of pregnancies and the number of children. For example, a woman on her second pregnancy would be "G2P1" but after giving birth would be "G2P2."
Current Pregnancy: If the patient is currently pregnant, date the pregnancy by asking about the last menstrual period and adding two weeks to get the date of conception. This is a rough estimate, and an ultrasound exam should be performed to give a more accurate timeline. Ask how the patient's health has been, whether there have been any issues. Get more information about any complications, the same as taking a history for any other chief complaint. Has the patient had any abdominal pain or discomfort? Ask about vaginal discharge and its consistency. Has there been any vaginal bleeding? Ask about contractions, how often they are occurring, and for how long.
Past Pregnancies: If the patient was pregnant previously, ask for more information. Were there any complications during each pregnancy, and how were they treated? How is the current health of their child(ren)?
(Post) Birth Planning: Is there anything specific the patient wants during the birth process? Has an epidural been discussed? Does the patient need a scheduled C-section? Will labor be induced? Discuss breast vs bottle feeding, as well as support systems for after birth. Talk to the mother about other safety issues, such as car seats and sleeping arrangements.
The gynecologic history focuses on female-specific health concerns. The issue is organization, as each section relates to every other section. There's many different orders to ask the questions in, so I've listed them in just one possible way. Feel free to organize it whichever way flows best for you. Don't forget to cover both the female genitals as well as the breasts.
Medical History: Always a nice way to start. Ask about fibroids, PCOS, and fibroids. Find out if the patient has any history of endometrial, cervical, ovarian, or breast cancer. Don't forget to ask about family history of cancer either!
Surgeries: Has the patient had any surgeries to treat any of their conditions? Have any of the female organs been removed, either for cancer or other reasons? Have her tubes been tied?
Screening Exams: Does the patient do self breast exams at home? Ask about the last mammogram and the last Pap smear. Now that there's an HPV vaccine (WHICH PREVENTS CANCER HOW GREAT IS THAT), has she been vaccinated?
Medications: Does the patient take birth control, either for birth control or for another reason? Is the patient on hormone therapy because they're post-menopausal? What about vaginal estrogen cream? Does the patient use other forms of birth control, such as implants?
Menstruation: Get an idea of the patient's menstrual cycle. At what age did she start menstruating, and if shes in her 40s or older, has she stopped menstruating? Are her cycles regular, how often do they occur? How many days do they last for, and how many pads/tampons does she use at the heaviest point in her cycle? Are there any other associated symptoms, such as cramping or bloating? Are periods painful?
Sexual Activity: This is one of the few times you ask yes/no questions. First, find out if the patient is even sexually active. Are they active with men, women, or both? Does the patient have one or multiple partners. When she says "sexually active," what sort of intercourse is she having? Does she use protection; if so, how often, and what kind?
STIs: Find out if she has a history of sexually transmitted infections; this can include chlamydia, gonorrhea, HIV, HPV, herpes, syphilis, and trichomonas. If so, did she have symptoms, and was she treated? What has she been screened for previously?