1 english / .. ID . Medical Questionnaire (Obstetrics and Gynecology)/ . Please check the appropriate . year month day Patient name/ Date/ . / / / . Date of birth/ year/ month/ day/ Sex/ Male/ Female/ . Height and weight/ cm kg Age/ years old/ . Language/ Nationality/ . Living condition/ . With family member(s) who require nursing care/ Have young children/ . Aged household/ Living alone/ Single parent/ . Other/ ( ). Employment/ . Full-time/ Part-time/ Self-employed/ . Retired/ Unemployed/ . What brought you here today?/ . Pregnancy/ Abnormal menstruation/ Vaginal discharge/ . Lower abdominal pain/ Irregular genital bleeding/ Polyps/ . Ovarian cysts/ Genital itchiness/ Uterine fibroids/ . Cancer screening/ Infertility/ Anemia/ . Fits/ Other/ ( ). When did the symptoms start?/ . Since approximately: year/ month/ day/ . About your menstrual periods/ . When was your first menstrual period?/ Age/ : years old/ . When was your menopause?/ Age/ : years old/ . How long is your menstrual cycle?
2 / . 28 days/ 28 30 days/ 30 days/ Irregular/ . On average, how long does your period last?/ . For days/ . How heavy is your flow?/ . Heavy/ Medium/ Light/ . Do you suffer from menstrual pain?/ . Yes/ No/ . When was the first day of your last period?/ . Date/ : month/ day/ . Have you ever had sexual intercourse?/ . Yes/ No/ . *Please fill in the next page(s) as . 1/3. 2014 . english / .. ID . Is there a possibility that you are pregnant?/ . Yes/ months pregnant/ I do not know/ No/ . Are you breastfeeding?/ . Yes/ No/ . Have you ever had a Pap test?/ . Yes/ Date/ : year/ month/ day/ No/ . Did this test reveal any abnormalities?/ . Yes/ No/ . Pregnancy history/ . Pregnancy/ Number of times: / . Delivery/ Number of times: / . Normal delivery/ Number of times: / . Abnormal delivery/ Number of times: / . Abortion and/or miscarriage/ Number of times: / . Miscarriage/ Number of times: / . Abortion/ Number of times: / . Other/ Ectopic pregnancy/ Hydatidiform mole/ . If you are pregnant, would you like to deliver in this hospital?
3 / . Yes/ No/ . Family Medical history/ . Age Healthy Not healthy Hereditary High blood Diabetes Cancer / / / disease pressure / / . / / . Father/ ( ) . Mother/ ( ) . Brothers/ ( ) . Sisters/ ( ) . Husband/ ( ) . Children/ ( ) . Are you currently undergoing treatment for any diseases?/ . Yes/ (Disease/ : ). No/ . Are you allergic to any foods or medications?/ . Yes/ Medication/ Food/ Other/ ( ). No/ . Are you currently taking any medications?/ . Yes/ Please show us the medications if you have them with . No/ . *Please fill in the next page(s) as . 2/3. 2014 . english / .. ID . Have you previously had any of the diseases listed below?/ . Gastrointestinal disease/ Liver disease/ Heart disease/ . Kidney disease/ Respiratory disease/ Blood disease/ . Brain / neurological disease/ Cancer/ . Thyroid gland disease/ Diabetes/ Other/ ( ). How old were you when you became ill?/ . Age: (years old)/ . Do you smoke?/ . Yes/ Current amount/ : cigarettes/day/ / Duration/ : years/ . No, but I used Previous amount/ : cigarettes/day/ / Duration/ : years/.
4 No/ . Do you drink alcohol?/ . Yes/ mL/day/ ml/ No/ . Have you ever had any surgery?/ . Yes/ No/ . When was the surgery?/ . Approximately: year/ month/ (type of surgery/ : ). Have you ever had any anesthesia?/ . Yes/ General anesthesia/ Local anesthesia/ . No/ . Did you have any problems related to the anesthesia?/ . Yes/ No/ . Have you ever had a blood transfusion?/ . Yes/ No/ . Did you have any problems related to a blood transfusion?/ . Yes/ No/ . Will you be able to bring an interpreter with you in the future?/ . Yes/ No/ . 3/3. 2014.