Gynaecological Examination Questionnaire Form

Please complete the form below to facilitate the gynaecological examination. It will take approximately 6 minutes to complete the form.

Need help? Contact us at 732 555 556 during working hours (Monday-Friday 8:00 AM - 9:00 PM).

Personal and Biophysical Data

First Name

Last Name

Contact Phone

Email Address

Date of Birth

Current Weight

Height

Menstrual Period Information

How old were you when you had your first period?

No first period

Date of last period (first day)

How many days is your menstrual cycle?

Are your menstrual cycles regular?

How many days does your period last?

Examination history

Result of the last cytology test

Date of last cytology test (year)

Don't remember

Result of the last mammography

Date of last mammography (year)

Don't remember

Result of the last breast ultrasound

Date of last breast ultrasound (year)

Don't remember

Pregnancy and Birth History

How many times have you been pregnant?

Medications taken

Do you take any medications?

Diseases, allergies, surgical procedures

Do you have any chronic diseases?

Please list the diseases

Do you have any allergies to medicines?

Please list your allergies to medicines

Have you had any surgical procedures?

Please list the surgical procedures

Family medical history

Have there been cases of breast cancer in your family?

Who in your family had breast cancer?

Have there been cases of colon cancer in your family?

Who in your family had colon cancer?

Have there been cases of endometrial cancer in your family?

Who had endometrial cancer?

Have there been cases of thrombosis in your family?

Who had deep vein thrombosis?

Have there been cases of pulmonary embolism in your family?

Who had pulmonary embolism?

Have there been cases of endometriosis in your family?

Who had endometriosis?

Have there been cases of polycystic ovary syndrome in your family?

Who had polycystic ovary syndrome?

Have there been cases of diabetes in your family?

Who had diabetes?

Stimulants

Do you consume alcohol?

Do you smoke cigarettes?

Do you use drugs?

Vaccinations

Have you been vaccinated against HPV?

Consent to the processing of personal data for the purpose of providing the service. Consent is voluntary but necessary for the service to be provided. Consent may be withdrawn at any time.
The administrator of the personal data is the Centrum Medyczne Drews/Medfemina Poznań Prosta Spółka Akcyjna. The full privacy policy can be found at: https://poznan.medfemina.pl/polityka-prywatnosci/.