Male History Form

Male Patient History Form

Personal Details

Aboriginal
Torres Strait Islander
cm
kg

Reproductive History

History of Sexually Transmitted Diseases (STD’s)?

History of Sexually Transmitted Diseases (STD’s)

Medical History

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

Current Medication

Any Known Allergies to Medications?

Medication Allergies

Previous Operations

Mental Health History

Diagnosis

Personal/Social

Smoking
Vaping

Family

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

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.

She consults and operates across Western Sydney and offers Saturday appointments, as well as telehealth bookings.

If you have a question about a condition or treatment, or would like to book an appointment, please contact us and one of our friendly staff members will happily assist you.