Questionnaire for clients

Client's personal data

Surname *

Name *

Maiden name

Date of birth *

Telephone (mobile) *

Telephone

Marital status

E-mail *

Home address *

ZIP code *

Uninsured person

Insurance *

Insurance number *

HUSBAND/PARTNER/RELATIVE

Surname

Name

Date of birth

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

Birth weight

Pregnancy duration

Labour duration

Birth process (spontaneous, forceps, caesarian section)

Breastfeeding duration

2. CHILD

Month and year

Gender of the child

Birth weight

Pregnancy duration

Labour duration

Birth process (spontaneous, forceps, caesarian section)

Breastfeeding duration

3. CHILD

Month and year

Gender of the child

Birth weight

Pregnancy duration

Labour duration

Birth process (spontaneous, forceps, caesarian section)

Breastfeeding duration

4. CHILD

Month and year

Gender of the child

Birth weight

Pregnancy duration

Labour duration

Birth process (spontaneous, forceps, caesarian section)

Breastfeeding duration

5. CHILD

Month and year

Gender of the child

Birth weight

Pregnancy duration

Labour duration

Birth process (spontaneous, forceps, caesarian section)

Breastfeeding duration

6. CHILD

Month and year

Gender of the child

Birth weight

Pregnancy duration

Labour duration

Birth process (spontaneous, forceps, caesarian section)

Breastfeeding duration

7. CHILD

Month and year

Gender of the child

Birth weight

Pregnancy duration

Labour duration

Birth process (spontaneous, forceps, caesarian section)

Breastfeeding duration

8. CHILD

Month and year

Gender of the child

Birth weight

Pregnancy duration

Labour duration

Birth process (spontaneous, forceps, caesarian section)

Breastfeeding duration

9. CHILD

Month and year

Gender of the child

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. *

I agree to receive premium services of Gyn Kup, s.r.o. *

I agree to process my personal data by Gyn Krup, s.r.o. *

Date

Your signature *

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