Personal and Hormonal Information

Mobile Phone

Regular GP

Age

Occupation

Martial Status

Do you have any children?

Please include number and ages

If yes, please specify

Tell us about your menstrual cycle

Include duration, frequency and bleeding pattern. If you no longer have a cycle, please record the approx date it ceased.

List any medical issues

Include the year diagnosed

Have you had a blood clot in the past?

If so, please list date and details

Have you ever had breast cancer?

Please include details and diagnosis year

List any surgeries / hospitalisations

Include reason, hospital name and year

List any drug allergies and reactions you have had

List your current prescribed medications

Include name of medication, strength and frequency taken

List any over-the-counter medications / vitamins / herbs

When was your most recent mammogram?

When was your most recent cervical screen (previously called pap smear)?

Have you had a bone density scan (DEXA)?

List any significant family medical history

Include relation, health problem and age diagnosed (if known)

Today's Date

Patient Forms

Hospital Admission Forms