Medical History For Female Partner

Gynaecological History:

At what age did your menstrual periods start?

Do you still have periods?

If no, are you menopausal?

If yes, do you take hormone replacement therapy?

Are your periods regular?

Date of last period How long did it last?

How many days between your periods?

Do you have very painful periods?

Do you have any bleeding in between periods? If yes, explain:

Do you suffer from a vaginal discharge? If yes, explain:

Do you experience discomfort during intercourse?

When was your last PAP smear?

Have you ever had an abnormal PAP smear result? If yes, explain

Do you use contraception? If yes, what type?

Do you have any problems with passing urine?

If yes, explain

Do you have any problems with your bowels? If yes, explain:

Other Gynaecological history

Obstetric History:

Number of pregnancies Dates

Number of miscarriages Dates

Number of termination of pregnancies: Dates

Number of children:

____ From this relationship:

____ From a previous relationship:

Are you Currently Breastfeeding? Children Male / Female Delivery Date Complications Height / Weight

Medical History:

Do you have any allergies: Please explain:

Do you have any present medical condition? Explain

Have you had hospitalisation for any medical condition? Explain

Are you currently taking any medication (prescribed or over the counter)?

Height in cm: Weight in kg:

Surgical History:

What previous operations did you have?

Family History:

Are there any specific medical conditions within your family? Explain

Social History:

What is your occupation?

Do you smoke? If yes, how many per day?

Do you drink alcohol? If yes, how often?

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