Female Questionnaire - JS

Pre-consultation Questionnaire

Pre-consultation Questionnaire
All biologically female patients should complete this questionnaire before seeing any of our doctors at MySexualHealth.co.za

The information you provide will remain fully confidential.

Please do not be offended by the nature of these questions. Since this is your first visit, we just want to make sure we have good background information. All patients answer exactly the same quesions, we do not imply anything by asking you these questions.

Where dates are requested, estimations are always appropriate.

Some fields are required and others not. If you do not complete a section that is not compulsory it will be assumed that you do not have a problem in this area or wish not to address it.

Contact Information
Full Name*

First NameLast Name
Date of birth*

DayMonthYear
What is your occupation?*

Menstrual Cycle
YesNo, I am post-menopausalNo, I had a hysterectomyNo, I have a MirenaNo and I don't know whyNo, but for other reasons
How many years have you been post-menopausal?
Why did you have a hysterectomy?
Please describe the other reasons why you are not menstruating

Obstetric History
Number of pregnancies
Number of Children
Number of C-Sections
What is the age of your youngest child in years?
What is the age of your youngest child in months
YesNo
YesNo

Fertility History
YesNo
Please write down any fertility treatment you have had in the past:
YesNo
YesNo
Please write down your blood group:

Please write down anything else you would like to bring under your Doctor's attention:
Should be Empty: