Gynaecology Intake Form

Surname

First Name

Preferred Name

Your DOB

Medicare

Aged Pension

Address

Email **

Mobile

Previous pelvic ultrasounds? If yes, where?

Referring Doctor

Next Appointment

MEDICAL HISTORY

Are you Post Menopause?

Yes No

Do you use any hormones?

Oral contraceptive Pill Menopausal hormone therapy Mirena IUD Implanon

Other

Have you had children? How many?

When was your last PAP smear/CST?

If you still have a menstrual cycle:

When was the first day of your last period?

How many days do you bleed for?

Is your cycle regular?

Yes No

How long is your typical cycle (eg 28 days)

Have you had any pelvic surgery?

Yes No

If Yes what?

Do you have any medical allergies?

Yes No

If Yes what?

Name of anyone attending with you

What is their relationship to you?

Privacy
QDOS ultrasound is commited to proctecting your privacy according to the Privacy Act. Access to computer records containing your information is retristed to staff, with varying access levels and is password protected. All hard copies of patient documents are disposed of in a secure manner. At times it may be necessary to email or fax your reports to other Medical Practitioners and Hospitals.
** We use the email you provide to forward invoices/receipts, medical reports if requested, and communication regarding appointments at QDOS ultrasound.

My Health Record

Do you want your ultrasound reports to go to My Health Record

Yes No

Signature

Date

Attach File Referral if Any (Accepted file types: pdf, jpg. Max. file size: 10 MB.)

Prefer to fill in a PDF?

QDOS Ultrasound provides specialist obstetric and gynaecology ultrasound performed by highly experienced and motivated doctors and sonographers. The rooms are purpose-built, located on the ground floor at 12 Connolly Street, West Leederville, at the rear of Connolly House, which is on the corner of Connolly and Cambridge Streets, opposite SJOG Hospital Subiaco.

Pregnancy

Gynaecology

Submit Referral & Patient Information here

Contact

Address
12 Connolly St, West Leederville
PERTH – Western Australia 6007

Monday – Friday
8:00 am – 4:45 pm
(strictly by appointment only)