First Name*

Surname*

Date*

Obstetric History

Have you delivered a baby vaginally? If yes, how many?*

Have you had a caesarean section? If yes, how many?*

Have you had a miscarriage? If so, how many?*

Have you had an ectopic pregnancy? If so, how many?*

Screening Tests

Year of last pap smear?*

Normal/Abnormal?
NormalAbnormalUnknown

Did you require treatment?
YesNo

Year of last mammogram?*

N/A

Have you had an abnormal mammogram?
YesNo

Year of last bone density?*

N/A

Have you had an abnormal bone density?
YesNo

Operations

Operations, year and any complications: eg. Appendicectomy, gastroscopy, wisdom teeth

Anaesthetics

Have you ever had a problem with anaesthetic?
YesNo

Medications

Including sedatives, aspirin, steroid, HRT, contraception, vitamins etc.:

Allergies

Any allergies YesNo

Medication name:

Allergy type:

Reactions? eg rash, vomiting, anaphylactic reaction:

Medical Conditions

Do you have, or have you ever had, any of the following:

Heart Problems
YesNo

High Blood Pressure
YesNo

Stroke
YesNo

Thyroid Problems
YesNo

Migraines
YesNo

Anxiety
YesNo

Depression
YesNo

Ulcers (gastric, duodenal)
YesNo

Genital Herpes
YesNo

Epilepsy/Fits
YesNo

Asthma
YesNo

Diabetes
YesNo

Anaemia
YesNo

Bleeding, bruising problems
YesNo

Recurrent Candida (thrush)
YesNo

Pelvic inflammatory disease
YesNo

Hepatitis B, C, HIV
YesNo

Deep Vein Thrombosis or Pulmonary embolus
YesNo

Do you have any other medical conditions:
YesNo

If yes, please specify:

Other Current Intake

Cigarettes YesNo

AlcoholYesNo

If yes, how many per day:

If yes, how many per day:

Recreational drugsYesNo

What type?

Relevant Family History

Please let any family members with a significant family history, including cancer. (Eg: mother’s sister – alive – 40 years old – breast, bowel or ovarian cancer)

Mother:

Father:

I have read all the questions and the information I have given is correct and complete to the best of my knowledge.

Patient signature*

Date*

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