Women s Health Associates Maitland

Transcription

1 Doctors Name First Name Last Name Preferred first name. Marital Status Date of Birth Street Suburb Postcode State Address Home telephone Work Telephone Mobile Number Please indicate how you would like us to contact you Occupation Medicare Number Medicare reference number (ie Number next to your name Expiry Date Do you have private Hospital cover Do you have a gold veteran card

2 These questions are relevant if If you are not menopausal/ and have a uterus Date of first day last Period Do you suffer from - Heavy periods - Painful periods - Prolonged periods - How long do your periods last, - How long between Are your periods bothering you sufficiently that you want it looked into Do you suffer from - Mid Cycle bleeding If you are beyond the menopause Have you suffered with post menopausal vaginal bleeding Do you suffer from hot sweats/ and other menopausal symptons Do you wish for this to be discussed

3 These are general questions - Do you suffer from vaginal dryness - Do you suffer from sex being painful - (Is it deep, or on entry) - Do you bleed after sex How many children have you had How many miscarriages have you had How many ectopic pregnancies have you had How many Caeserean sections How many forcep deliveries? Did you ever have an extensive tear at delivery What contraception do you use (includes vasectomy) Or are you trying to get pregnant Y/N When was your last smear Have you had an abnormal smear Have you had treatment for an abnormal smear

4 These are general questions What operations have you had in the past What medications do you take Are you allergic to any medications Do you smoke, Y/N, if so how many? Do you suffer from - Diabetes - Asthma - Blood pressure - Stroke - Heart attack - Blood clot in your leg/arms

5 These questions relate to pain Do you suffer from lower abdominal pain Is there a pattern to it Does anything make it worse Does anything make it better Where is the pain Does it spread What is its nature How long does it last for How many times a day will you get pain How many times a week will you get pain Does it related to opening your bowel Does it relate to passing urine These questions relate to your bladder and your bowel - Do you suffer from constipation How many times do you open your bowels during the week - Is there ever blood in your poo Does your bowel habit alternate between being soft and constipated - Do you leak when coughing or sneezing - Do you have a sudden urge to go to the toilet without warning - Will you leak if you get an urge and can t get to the toilet How often do you pass urine during the day - How often do you get up at night to pass urine - Do you have difficulty starting to urinate

6 - Do you feel that you incompletely empty your bladder - Do you strain to empty your bladder - Do you have to sit down again to empty your bladder - Do you dribble when standing up after emptying your bladder - Are your bladder symptoms bothering you? - Do you wish for this to be discussed y? - Have todayou had treatment (eg physio/medications) for this? Are you aware of prolapse (ie a sensation of a bulge or lump in the vagina, or hanging out beyond the vagina) - If so Does it causing irritation or rubbing These questions are relevant if you are bothered by vulval pain) (pain on the outside of the vagina) How long you have had vulval pain for (pain on the outside of the vagina) - Did anything trigger it - Does anything make it worse - Does anything make it better - Do you use any ointments/creams What is the nature of the pain - itchy, burning, scratchy Can you identify a particular area which is more painful Do you suffer from acne/ greasy skin/ more body hair than you think you should have? Can you give list previous Doctors that have previously treated you for your gynaecology conditions. Please tick, to acknowledge that we have your permission to obtain health records from prior health providers and to share information with your primary care provider/referring doctor.