New Patient Questionnaire

First name

Last name

Birthday

Day

Month

Year

Current concerns / reasons for making the appointment:

Gynaecological History:

Date of last menstrual period:

Cycle length : i.e. The number of days between the 1st day of your period and the 1st day of your next period

Date of last cervical smear:

Type of contraception currently used: e.g. the pill/implant/injection/coil

Date of last mammogram

Have you had the HPV Vaccination? If yes, provide date

Any past gynaecological problems or infections?

Do you have any children? How many? Caesarean section or normal delivery?

Have you had any other pregnancies? (e.g. Miscarriage / ectopic pregnancy)

How tall are you?

What is your current weight?

Do you have any medical problems? Please specify

Have you had any major operations? Please specify

Are you on any regular medications? Please specify

Do you have any allergies? Please specify

Do you smoke? Yes/No How many per day?

Alcohol consumption: Minimal / Moderate / Above average

Are there any medical problems that run in your family? Please specify: