Online Patient Form (English)
DATE:
FILE NO:
PATIENT NAME:
SURNAME:
AGE:
OCCUPATION:
MARITAL STATUS:
PARTNER NAME:
PARTNER OCCUPATION:
MAIN COMPLAINTS:
1:
2:
3:
INFERTILITY: Do you suffer from infertility?........................IF YES, please complete the infertility questionnaire. (kindly request from receptionist)
REFERRAL
Have you been referred?
By who?
Medical Practitioner
Friend or Family member
Internet
Self
Have you consulted a doctor in the past 6 months?
Have you had any blood tests done in the past 6 months?
When?
Which Lab?
Did you have any other Special examinations? (Example: Mammogram,DXA?)
If “Yes” please specify dates:
Are you current Pregnant?
CONTRACEPTION:
Are you sexually active?
What contraception do you use?
PREGNANCIES:
How many times have you become pregnant?
Have you ever had any cesarean sections?
miscarriages/abortions?
premature birth s (> 3 weeks early)?
After your pregnancy did you breastfeed?
suffer from depression?
Year of pregnancies
Male/Female
Method of Delivery
Gestation/duration of Pregnancies
Complications
PAP SMEAR
When was your last pap smear?
Was it ever abnormal?
MENSTRUATION: At what age did your Menstruation start +/
LNM : When was your last normal
DESCRIBE YOUR CYCLE:
Regular
Irregular
Skip cycles?
Menstruate more than once/month?
What was the first day of your last period?
How many days does your menstrual flow last?
How would you describe your menstruation?
Normal
Heavy
Light
DYSMENORRHEA:
Do you have pain with your pe riods?
Little
Moderate
Severe
Do you need to take Pain medication?
DYSPAREUNIA
Do you have pain with intercourse?
If YES, please specify
Deep Pain
Vaginal Pain
ENDOCRINE: Do you suffer from:
hot flushes?
eating disorder?
sleep abnormality?
depression?
headaches?
Vision disturbance?
OTHER GYN HISTORY
Does your breasts leaks?
Is the hair on your face, breasts or abdomen increasing?
Acne Face
Back
DO YOU SUFFER FROM INFECTION
Vaginal?
Itching
Burning
Odor
Discharge
Have you ever had sexually transmitted disease?
When was your last HIV test done?
URINARY SYSTEM
Do you suffer from urinary infections?
Do you have urine leak?
If yes: Does it cause embarrassment?
Leak when cough/Laugh/Jump?
Leak before you reach the toilet?
o you have to go frequently?
How many times do you wake up at night to go to the toilet?
Do you have a heavy feeling or a lump in the vagina?
SURGERY
Have you had any Gynecological surgery?
Specify
Do you still have your Appendix?
LAPAROSCOPIC SURGERY
[Reason if yes]
OTHER SURGERY
Have you had any other operations?
Please Specify
PERSONAL MEDICAL HISTORY
Do you suffer any serious medical conditions? (Please circle)
DiabetesHeart diseaseHigh blood pressureLiver problemsJaundiceMigraineTuberculosisThyroidEpilepsyCongenital hyperlipidemiaSickle cell disease
FAMILY HISTORY
Do you have a close family history of breast cancer
Who? Mother sideFather side
ovarian cancer?Endometriosis?Osteoporosis?
Close Family members with: (Please circle)
TREATMENT:
Do you take daily medication? If YES, please elaborate
Do you take any Aspirin (Disprin and/or Grandpa etc.)
Do you take any NSAID (Voltaren and or Brufen etc.)
ALLERGIES
Are you allergic to any drugs?
SOCIAL
Do you Smoke
Stopped: When?
Do you use excessive alcohol?
Do you use any recreational drugs?
Exercise:
What type of exercise do you do?
How many times a week?
BOWEL
Are your bowel movements regular/normal?
Constipation?
Loose stools?
Blood in the stool?
Hemorrhoids?
Are you losing weight?
EXERCISE:
Would you like a Chaperone to accompany you in the examination room?
What religion/church are you attending?
Services & Conditions Schedule a Consultation
When women take care of their health, they become their best friend.
MAYA ANGELOU Poet
If you’d like to schedule an appointment, let us know what days or times suit you and we’ll do our best to accommodate your schedule.
First Name
Surname
Email*
Contact number*
Enter date
Message
