Health Questionnaire Form Personal Details 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?* Have you had an abortion? 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.: Medical Conditions - Do you have, or have you ever had, any of the following: Heart Attack YesNo Heart Problems YesNo Rheumatic fever 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 Deep Vein thrombosis or Pulmonary embolus YesNo Recurrent Candida (thrush) YesNo Pelvic inflammatory disease YesNo Chlamydia/gonorrhoea YesNo Hepatitis B,C, HIV YesNo Do you have any other medical conditions: YesNo If yes, please specify: Other Current intake Cigarettes YesNo If yes, how many per day: Alcohol YesNo If yes, how many per day: Recreational drugs YesNo What type? Allergies Drug(Eg. Penicillin) YesNo Medication name: Reactions? eg rash, vomiting, anaphylactic reaction: 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*