Female History Form

Personal Details

Name

Age

Gender

Preferred Pronouns Preferred Pronouns

Country of Birth

State (If in Australia)

Ethnicity

Aboriginal

Yes

Torres Strait Islander

Yes

Height

Weight

BMI

Reason for Consultation

Presenting Problem(s)

Together Since (Date)

Trying to Conceive Since (Months/ Years)

Trying to Conceive Since

Contraception Used (past/current – stopped when?)

Previous Fertility Investigations

When

By Whom

Tests/Treatments

Outcome

Add Remove

Previous Deliveries

When

How many weeks

Details / Place

Complication (if any)

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Terminated Pregnancies (if any)

When

How many weeks

Details / Place

Complication (if any)

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Miscarriages

When

How many weeks

Details / Place

Complication (if any)

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Ectopic (Tubal Pregnancies)

When

How many weeks

Details / Place

Complication (if any)

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Gynaecological History

Menarche (Age of first period)

Last Menstrual Period

Cycle (regular/Irregular)

Length (e.g. 28 days)

Period (days of bleeding)

Bleeding Light/Moderate/Heavy

Painful Mild/Moderate/Severe

Have you had a Cervical Screening Test (Pap Smear) ?

Yes

Cervical Screening Test (Pap Smear)

When

Where

Results

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Sexual History

Current Relationship (How long have you been together?)

Partner’s Name

Sex (Times per week)

Pain during intercourse?

Contraception (Current/Previous, any complications)

History of Sexually Transmitted Diseases (STD’s)?

Yes

History of Sexually Transmitted Diseases (STD’s)

When

What Type

Treatment

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Other Information

Abnormal bleeding between periods e.g. spotting, after sex?

Abnormal vaginal discharge?

Urinary problems e.g. Incontinence, urgency, nocturia (up at night)?

Bowel problems?

Excess hair on chin, chest, back, breasts?

Acne?

Recent weight changes, if any?

Do you have any medical history?

Yes

Medical History

Are you known to have any of the following medical problems?

Current Medication

Current Medications (prescribed)

Any Known Allergies to Medications?

Yes

Medication Allergies

Drug Name

Type of Allergy

Add Remove

Have you had previous operations?

Yes

Previous Operations

When

Which Hospital

Operation name and details

Complications (if any)

Add Remove

Mental Health History

Diagnosis

Anxiety

Depression

Other (please specify)Other (please specify)

Medication/Treatment if any

Personal/Social

Alcohol (standard drinks per week)

Smoking

Yes

How Many Per Day

Quit (when)

Vaping

Yes

How Many Per Day

Quit (when)

Recreational drugs (Marijuana/other)

Family

Any known genetic/inherited conditions (Cystic Fibrosis, Muscular Dystrophy, Fragile X Syndrome) Family History of Breast/Ovarian, Bowel cancers?

Family History of Diabetes, Heart Disease, Strokes, Endometriosis, Polycystic Ovaries? Please Specify. (eg. Mother, Father, Brother and name of condition)

Privacy Notice & Consent

Dr Shree Mane acknowledges all obligations regarding patient confidentiality as stated in the Australian Privacy Principles and The Privacy Amendment (Enhancing Privacy Protection) Act 2012.

Personal information collected by this practice, either written or through the consultative process, will be used exclusively to achieve optimal health care for you. We may however be obliged to share this information with other health organizations for statistical or reporting purposes as considered necessary under the relevant legislation.

Sometimes examinations (both females and males) will be required as an important part of your care and treatment. The doctor will explain why such an examination is required, what it involves and whether this will include an ultrasound.Youareallowedtodeclinesuchanexaminationifthatisyourwish. Ifyouhaveanyconcernsaboutsuch examinations, speak with the doctor.

Attention is paid to your privacy and comfort and you may nominate to have a chaperone present at the time of your examination.Thiscanbeamemberofthepracticestafforsomeoneyouhavebroughtwithyou. Underthe“RANZCOG Guidelines” a chaperone is to be offered but is not mandatory.

Consent

You consent to us collecting, using and disclosing your personal information, including sensitive information, in the way described in this notice

You consent to us and others involved in your treatment exchanging your personal information by unencrypted (ie. normal) email.

I understand that if an examination is required, I can request a chaperone be in attendance

I consent to an ultrasound being undertaken as part of my diagnosis, but I also understand I have the right to decline this at the time of consultation and this will be duly noted in my records

You consent to us sharing your personal information with your partner or next of kin

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Fertility

Gynaecology

Obstetrics

Clinic Information

Personal Details

Reason for Consultation

Previous Fertility Investigations

Previous Deliveries

Terminated Pregnancies (if any)

Miscarriages

Ectopic (Tubal Pregnancies)

Gynaecological History

Cervical Screening Test (Pap Smear)

Sexual History

History of Sexually Transmitted Diseases (STD’s)

Other Information

Medical History

Current Medication

Medication Allergies

Previous Operations

Mental Health History

Personal/Social

Family

Privacy Notice & Consent

Dr Shree Mane is a Sydney Obstetrician and Gynaecologist, and Fertility Medicine sub-specialist with 30+ years of experience. She has achieved specialist registration in India, the United Kingdom and Australia.

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