Medical Questionnaire

Please complete this form before your appointment to ensure that Mr Gangar has all the relevant information to hand.

Items marked with * are essential

Surname*

First name*

Address*

Postcode

Phone*

Home

Mobile*

Work

Postcode

Email*

Which GP Practice are you registered with?
GP Address

Postcode

Your details

Age*

Date of Birth*

Occupation

Marital Status

Height*

Weight*

Your gynaecological health

Have you had a hysterectomy?
YesNo

If yes, in which year

month & year if possible

..............................................................................................................................................................................................................................................

If you are still having periods:

How long do your periods last?

How often do you get a period?

Do you have any bleeding between periods?

Do you have any bleeding after intercourse?

Have you had any gynaecological problems in the past?

Do you take any tablets or medicines on a regular basis?

If yes, what?

Are you allergic to any medicines such as antibiotics?

Do you smoke?
YesNo

If yes, how many per day?

Do you drink?
YesNo

If yes, how many per week?

What contraception do you use?

Have you had any pregnancies?

Number of children and their ages?

Date of your last cervical smear (taken from the neck of the womb)

Date of last mammogram (if applicable)

Have you had any breast lumps in the past?

Is there any history of breast or ovarian cancer in the family?

Have you had any operations?

Are there any serious diseases, which run in your family?

Please describe your symptoms or add any further information you feel is relevant

Do you have Medical Insurance? If yes, please supply name and membership details

Information/Communication Consent Form

From time to time we may need to contact you with regards your appointments. At no time would our messages contain any sensitive information nor would we speak to anyone other than yourself. If you are happy for us to contact you by phone, please complete the following.

I agree to receive text messages regarding my appointments.
I am happy to have messages left on my answerphone.
I am happy to receive clinical letters and other correspondence on the above email address.

Date

Consent

Clicking Submit Questionnaire acts as your signature and consent.

“Please answer all questions as far as possible”