Gynaecology Patient Questionnaire

A pre-visit questionnaire that lets a patient refresh her records and clinical history before she walks into the consulting room. It covers the menstrual cycle, contraception, pregnancy plans, symptoms, diet, exercise and preventive care. Clinicians arrive at the appointment with the full picture and spend the visit on what matters.

Use this template

Name

Nombre

Apellido

Date of birth

Today's date

Age

Has your contact or insurance information changed since your last visit?

First day of your last period, or the final year of menstruation if you are past menopause

If you are under 55, which method of birth control do you use?

Are you planning a pregnancy in the next six to twelve months?

Yes No Not sure

If you answered yes to anything above, please explain here

Do you exercise regularly?

Yes No

Level of exertion

Light Moderate Vigorous

How many days per week?

Duration in minutes per session

When was your last dental check-up?

When was your last eye examination?

Describe any questions or concerns you would like to raise

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