Patient Form | Dr Deshini Packirisamy

Gynaecology & Obstetrics Patient Questionnaire

Date:

Name:

Age:
years

ID / File No:

Contact Number:

1. Presenting Complaint

What is the main reason for your visit today?

2. Menstrual History

3. Obstetric History

Number of pregnancies:

Number of deliveries:

Mode of delivery (tick all that apply):
Normal vaginal deliveryCaesarean sectionAssisted (forceps/vacuum)

Pregnancy losses:

Miscarriages (number):

Terminations (number):

Ectopic pregnancy:
YesNo

Complications in pregnancy or delivery?
YesNo

If yes, please specify:

4. Gynaecological History

Current contraception (if any):

Pain during intercourse (dyspareunia)?
YesNo

History of abnormal Pap smear?
YesNo

Date of last Pap smear:

Date of last mammogram (if applicable):

Sexually transmitted infections (STIs)?
YesNo

If yes, specify:

5. Urogenital Symptoms

Do you experience any of the following? (tick all that apply)

Urinary frequencyPain or burning on urinationUrinary incontinenceVaginal dischargeVaginal itching or irritationPelvic pain

Please provide details if applicable:

6. Medical History

Do you have or have you ever had any of the following? (tick all that apply)

High blood pressureDiabetesThyroid diseaseAsthma / lung diseaseHeart diseaseBlood clots (DVT/PE)EpilepsyMental health conditions

Other (please specify):

7. Surgical History

Have you had any previous surgeries?
YesNo

If yes, please list (including gynaecological or obstetric surgeries):

8. Family History

Is there a family history of:

Breast cancerOvarian cancerUterine cancerColon cancerDiabetesHigh blood pressureBlood clots

Other significant conditions:

9. Allergies

Are you allergic to any medications or substances?
YesNo

If yes, please list and describe reaction:

10. Medications

List all current medications, supplements, or hormonal treatments:

11. Social History

12. Additional Information

Is there anything else you feel the doctor should know?

Patient Signature: