Questionnaire for clients
Client's personal data
Surname
*
Name
*
Maiden name
Date of birth
*
Day
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Month
1
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12
Year
1900
1901
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1904
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1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
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1989
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2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Telephone (mobile)
*
Telephone
Marital status
Choose from the list
Single
Married
Divorced
Widow
E-mail
*
Home address
*
ZIP code
*
Uninsured person
Insurance
*
Choose your insurance
111 - Všeobecná zdravotní pojišťovna České republiky
201 - Vojenská zdravotní pojišťovna České republiky
205 - Česká průmyslová zdravotní pojišťovna
207 - Oborová zdravotní pojišťovna zaměstnanců bank, pojišťoven a stavebnictví
209 - Zaměstnanecká pojišťovna Škoda
211 - Zdravotní pojišťovna ministerstva vnitra České republiky
213 - RBP, zdravotní pojišťovna
Insurance number
*
HUSBAND/PARTNER/RELATIVE
Surname
Name
Date of birth
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Telephone
WHO CAN BE INFORMED ABOUT THE HEALTH STATUS
Surname
Name
Password
Personal and family history
Cardiovascular diseases
High blood pressure
Thrombosis, embolism, blood clotting disorders
Breathing difficulties, asthma
Digestive disorders (stomach, gallbladder, bowel)
Urinary tract and kidney diseases (inflammations, colic)
Neurological disorders (migraine, epilepsy)
Endocrinological disorders (thyroid gland)
Diabetes
Infectious diseases (childhood, jaundice)
Sexually transmitted and skin diseases
Muscoloskeletal diseases, back pain
Rheumatological disorders
Allergies (drugs, food, metals, pollen, dust)
Tumours - benign, malignant
Surgery and injuries
Regularly used medicines
Smoking, alcohol, drugs
GYNAECOLOGICAL HISTORY
Menstrustation from
What age
Cycle length
Number of days of bleeding
Bleeding intensity
Pain
First day of the last menstruation
Last cytology
BIRTHS
1. CHILD
Month and year
Gender of the child
Choose from the list
Male
Female
Birth weight
Pregnancy duration
Labour duration
Birth process (spontaneous, forceps, caesarian section)
Breastfeeding duration
2. CHILD
Month and year
Gender of the child
Choose from the list
Male
Female
Birth weight
Pregnancy duration
Labour duration
Birth process (spontaneous, forceps, caesarian section)
Breastfeeding duration
3. CHILD
Month and year
Gender of the child
Choose from the list
Male
Female
Birth weight
Pregnancy duration
Labour duration
Birth process (spontaneous, forceps, caesarian section)
Breastfeeding duration
4. CHILD
Month and year
Gender of the child
Choose from the list
Male
Female
Birth weight
Pregnancy duration
Labour duration
Birth process (spontaneous, forceps, caesarian section)
Breastfeeding duration
5. CHILD
Month and year
Gender of the child
Choose from the list
Male
Female
Birth weight
Pregnancy duration
Labour duration
Birth process (spontaneous, forceps, caesarian section)
Breastfeeding duration
6. CHILD
Month and year
Gender of the child
Choose from the list
Male
Female
Birth weight
Pregnancy duration
Labour duration
Birth process (spontaneous, forceps, caesarian section)
Breastfeeding duration
7. CHILD
Month and year
Gender of the child
Choose from the list
Male
Female
Birth weight
Pregnancy duration
Labour duration
Birth process (spontaneous, forceps, caesarian section)
Breastfeeding duration
8. CHILD
Month and year
Gender of the child
Choose from the list
Male
Female
Birth weight
Pregnancy duration
Labour duration
Birth process (spontaneous, forceps, caesarian section)
Breastfeeding duration
9. CHILD
Month and year
Gender of the child
Choose from the list
Male
Female
Birth weight
Pregnancy duration
Labour duration
Birth process (spontaneous, forceps, caesarian section)
Breastfeeding duration
SPONTANEOUS ABORTIONS / ABORTIONS / ECTOPIC PREGNANCIES
1. CASE
Month and year
Week of pregnancy
Surgery, possible complications
2. CASE
Month and year
Week of pregnancy
Surgery, possible complications
3. CASE
Month and year
Week of pregnancy
Surgery, possible complications
4. CASE
Month and year
Week of pregnancy
Surgery, possible complications
5. CASE
Month and year
Week of pregnancy
Surgery, possible complications
6. CASE
Month and year
Week of pregnancy
Surgery, possible complications
7. CASE
Month and year
Week of pregnancy
Surgery, possible complications
8. CASE
Month and year
Week of pregnancy
Surgery, possible complications
9. CASE
Month and year
Week of pregnancy
Surgery, possible complications
PREVIOUS GYNECOLOGICAL PROBLEMS (cyst, fibroid, suspicious finding on the cervix, irregular bleeding, last cytology, etc.))
REASON FOR VISITING THE GYNAECOLOGIST
Regular annual examination
Regular pregnancy care - antenatal counselling
Control due to cervical finding, uterine fibroid, ovarian cyst
Discharge, pain in the lower abdomen, urinary problems, irregular bleeding
Difficulties with getting pregnant
Counselling on contraception / emergency contraception
Counselling to address menopausal problems
Other
Confirmation and submission of the form
I was informed about the prices of premium services of Gyn Krup, s.r.o.
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I agree to receive premium services of Gyn Kup, s.r.o.
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I agree to process my personal data by Gyn Krup, s.r.o.
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