Obstetrics and Gynaecology Acquaintance Form Title: Miss / Ms / Mrs / Mr Name * First Name Last Name Date of birth: DD/MM/YYYY * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Mobile phone * Work phone Email * Occupation Partner's name Partner's occupation Home phone Partner's mobile phone Medicare number * Ref. no * Expiry * Do you have private health cover? * Yes No If so, are you covered for obstetrics? Yes No Private health fund name Name on card Membership number Ref. no YOUR MEDICAL HISTORY Do you have current or past medical problems? (Please specify e.g. heart problems, high blood pressure, epilepsy, diabetes, hepatitis, kidney, thyroid) * Have you had any operations? (Please specify) * Do you have any gynaecological problems? (Please specify) * My last pap smear was on: Was it normal? Are you taking any medications or tablets? (Please specify) * Are you allergic to any medications? (Please specify) * Do you smoke? * Yes No If so, how many per day? Did you smoke previously? * Yes No If so, when did you stop? Do you drink alcohol? * Yes No If so, how many drinks per week? Do you use recreational drugs? * Yes No Have you ever received a blood transfusion? * Yes No THE FOLLOWING QUESTIONS APPLY TO YOU, YOUR FAMILY, AS WELL AS YOUR PARTNER AND THEIR FAMILY: Is there a family history of the following conditions? Cleft lip or palate * Yes No Down syndrome * Yes No Heart defects at birth * Yes No Cystic fibrosis * Yes No Spina bifida * Yes No Kidney disorders * Yes No Mental retardation * Yes No Blood disorders * Yes No How did you find out about us? Thank you!
