Patient Medical Form

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Take your time to fill out the questionnaire. The information you provide gives A/Prof. Tsaltas a good understanding of your circumstances prior to your consultation.

Patient Details

No information is saved on our website. This form must be completed in full and will only be sent to us when you press the submit button.

Patient Name*

Title First Last

Patient Date Of Birth*

Phone*

Email*

Patient Partners Name

Title First Last

Patient Partners Date Of Birth

Patient Medical History

This section is for IVF & Gynae patients

How old were you when you had your first period?

On average, how long is your cycle?

(From the 1st day of your period until the 1st day of your next period)

Is your period painful?

Yes

Do you feel that the amount of blood loss is abnormal?

Yes

Do you have a lot of symptoms prior to your period?

Yes

Is there vaginal blood loss between your periods?

Yes

Is intercourse painful?

Yes

Have you been diagnosed with Endometriosis?

Yes

Do you or your GP think you have Endometriosis?

Yes

Have you ever been Pregnant?

Yes

When was your last pregnancy?

Please specify how many pregnancies you have had below with your current partner

Miscarriages

Terminations of Pregnancy

Ectopic Pregnancies (e.g. in the tube)

Live Births

Please specify how many pregnancies you have had below with previous partners

Miscarriages

Terminations of Pregnancy

Ectopic Pregnancies (e.g. in the tube)

Live Births

If you are trying to get pregnant, how many months have you been trying to get Pregnant?

Have you ever received any fertility treatment?

Yes

Specifics of fertility treatment?*

Have you ever used / received contraception?

Yes

Specifics of contraception?*

Lifestyle

Weight (kg)

Height (cm)

Have you lost or gained a lot of weight recently?

Yes

Do you smoke?

Yes

How many cigarettes do you smoke a day?*

Do you drink alcohol?

Regularly

Rarely

Never

When was your last Pap Smear?

Was your last Pap Smear normal?

Yes

What was the Pap smear abnormality?*

Have you ever had an operation?

Yes

Have you ever had a Caesarean Section?

Yes

Details of Caesarean Section/s*

Example: Year, amount, type of procedure, outcome or result.

Have you ever had an operation on the cervix?

Yes

Details of operation on the cervix*

Example: Year, amount, type of procedure, outcome or result.

Have you ever had Laparoscopy (telescope through the belly-button)?

Yes

Details of Laparoscopy*

Example: Year, amount, type of procedure, outcome or result.

Have you ever had a Gynaecological Operation via abdominal incision?

Yes

Details of Gynaecological Operation via abdominal incision*

Example: Year, amount, type of procedure, outcome or result.

Have you ever had an operation on the Bowel (e.g. appendectomy)?

Yes

Details of operation on the Bowel*

Example: Year, amount, type of procedure, outcome or result.

Have you ever been treated for diabetes?

Yes

Have you ever been treated for Thyroid Disease?

Yes

Have you ever been treated for Tuberculosis?

Yes

Have you ever been hospitalised for an illness?

Yes

Specifics of why you were hospitalised for an illness*

Do you have any diseases that run in the family?

Yes

Provide details of diseases that run in the family*

Are you on any regular medication?

Yes

Provide details of regular medication*

Do you have any allergies (medication, food)?

Do you know of any inherited family illnesses?

Are you under any other specialist practitioners?

Are you on any alternative medicines?

Personal remarks

Male Partner Details

This section is for males presenting with infertility

Lifestyle

Weight (kg)

Height (cm)

Have you lost or gained a lot of weight recently?

Yes

Do you smoke?

Yes

How many cigarettes per day?*

Do you drink alcohol?

Regularly

Rarely

Never

Have you ever been treated for Diabetes?

Yes

Have you ever been treated for Thyroid Disease?

Yes

Have you ever been treated for Liver or Kidney Disease?

Yes

Have you ever been treated for Chronic Lung Disease?

Yes

Do you know of people in your family who have inherited condition?

Yes

Specify inherited condition*

Have you ever had an operation?

Yes

Have you ever had an operation on one / both testicles?

Yes

Details of operation on one / both testicles*

Example: Year, amount, type of procedure, outcome or result.

Have you ever had Vasectomy?

Yes

Details of Vasectomy*

Example: Year, type of procedure, outcome or result.

Have you ever had an operation on your bladder?

Yes

Details of operation on your bladder*

Example: Year, amount, type of procedure, outcome or result.

Have you ever had an operation on your prostate?

Yes

Details of operation on your prostate*

Example: Year, amount, type of procedure, outcome or result.

Have you ever had an operation on your penis?

Yes

Details of operation on your penis*

Example: Year, amount, type of procedure, outcome or result.

Have you ever had an inguinal hernia repair?

Yes

Details of inguinal hernia repair?*

Example: Year, amount, type of procedure, outcome or result.

Have you ever had an operation on your spinal cord?

Yes

Details of operation on your spinal cord*

Example: Year, amount, type of procedure, outcome or result.

Have you ever had mumps?

Yes

What age did you have mumps?*

Have you ever experienced severe pain in one / both testicles?

Yes

Have you ever been treated for undescended testicle?

Yes

Have you ever been treated for a urinary infection?

Yes

Have you ever had problems with erection / ejaculation?

Yes

If you have had other partners, were any of them ever pregnant?

Yes

Are you on any regular medication?

Yes

Specify any regular medication*

Do you have any allergies (medication, food)?

Personal remark

Privacy Statement

Consent*

This medical practice collects information from you for the primary purpose of providing quality healthcare. We ask you to provide us with your personal details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your healthcare needs. We may use the information you provide for administrative purposes in running our medical practice including billing and compliance with Medicare and the Health Insurance Commission. Information may be shared with other practitioners involved in your care. Confidentiality will always be maintained if any information related to your care is used in research, quality assurance or educational purposes.

I consent to the handling of my information by this practice for the purpose set out above.

Full Name Of Patient/Guardian Consenting*

Date*

Patient Details

Patient Medical History

Male Partner Details

Privacy Statement

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