Female Questionnaire - ER

  • Female Questionnaire

    Pre-consultation Questionnaire for Dr. Elna Rudolph

  • Dear patient,

    Thank you for taking the time to answer these questions.  It will make the time we spend together during your consultation much more effective. 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 prefer not to address it.

    We look forward to meeting you at one of our MSH Licensed Practice soon!

  • Contact Information

  • Gender:

  • Menstrual Cycle

  • Are you menstruating regularly?*

  • Menstrual Details

  • Is your period sometimes irregular?
  • Spotting/bleeding between periods?
  • Do you suffer from severe PMS?
  • Do you suffer from headaches when menstruating?
  • Do you suffer from severe menstrual pains?

  • Hormones and Contraceptives

  • Are you using any form of hormone replacement therapy?, including testosterone?
  • Are you using any form of contraception?*
  • Please indicate which form of contraception you are using:

  • Please indicate which type of injection you are using
  • Please indicate which type of pill you are using

  •  - -

  • Sexual History

  • Please indicate your current relationship status:

  • Do you have sex without condoms?
  • What is your sexual orientation

  • Are you concerned about having a possible sexually transmitted infection?
  • Please indicate if you have ever had one or more of the following infections:

  • Sexual Dysfunction

  • Are you concerned about having a low sex drive?
  • Do you struggle to become sexually aroused?
  • Are you concerned about how difficult it is for you to achieve and orgasm?
  • Do you experience pain during sex?
  • Do you experience bothersome pain in your pelvis or genitals even when you are not having sex?

  • Obstetric History

  • Are you still breast feeding?
  • Are you currently trying to fall pregnant?

  • Fertility History

  • Have you been trying for more than a year?
  • Did you have difficulties with your previous pregnancy/ies or during labour?
  • Are you taking folic acid supplements?

  • Medical conditions

    Do you have any of the following?
  • Allergies?*
  • High Blood pressure?*
  • A tendency to form blood clots (ever had a stroke, pulmonary embolism or DVT)*
  • Do you have a family history of a tendency to form blood clots? (stroke, pulmonary embolism or DVT)*
  • High Cholesterol
  • Family history of breast cancer?*
  • Lumpy or sore breasts?
  • Hot flushes
  • Vaginal Dryness
  • Endometriosis?
  • PCOS (Polycystic ovarian syndrome)
  • Recurrent Candida/yeast infections?
  • Abnormal vaginal discharge?
  • Any sores or growths on your genitals?
  • Constipation?
  • IBS (irritable bowel syndrome)
  • Urinary frequency or burning urine
  • Abdominal pain?

  • Lifestyle

  • Do you smoke?
  • Did you use any recreational drugs in the last year?
  • How many units of alcohol do you use per week? (One unit equals a small glass of wine, a small bottle of beer or one tot of hard liquor)
  • Do you get 30 minutes of exercise five times a week (or the equivalent)?

  • Pap Smear

  • Have you had a pap smear before?*
  •  - -
  • Have you ever had an abnormal pap smear?
  • Please indicate the abnormality if you know what it was

  • Medical Examinations

  • Please inidcate which of the following medical examinations you have had in the last two years: (Please tick the name of the test and "normal" or "abnormal" for each test that you have had)
  • Should be Empty: