Medical History

Please complete the following medical history ahead of your first group consultation.

The information below will be used by your GP to determine medical advice and treatment options.

personal

medical history

What is your height in cm?

Please consult this table for help on converting from feet and inches to cm.

What is your weight in kilograms?

Please consult this table for help on converting from stones and pounds to kilograms.

Have you had your blood pressure measured in the last 6 months? If so, please provide readings.

Blood Pressure - Systolic

Blood Pressure - Diastolic

Have you experienced any of the following symptoms?

Please check all that apply

Which of the symptoms above affect you the most?

Please list any allergies:

GYNAECOLOGICAL HISTORY

Are you sexually active?

Do you have a history of sexually transmitted infections?

Have you had an abnormal cervical smear test?

How many times have you been pregnant, if any?

How many vaginal deliveries have you had, if any?

How many C-sections have you had, if any?

How many miscarriages or abortions have you had, if any?

social history

Have you ever smoked?

How many packs a day do/did you smoke?

Do you drink alcohol?

How many units do you drink per week?

Please consult this page for help on calculating number of units.

FAMILY history

Does anyone in your family or first-degree relatives have any of the following?

Please check all that apply

What other medical conditions run in your family?

If none, is there anything else you would like to mention?

Ethinicity

Which one best describes your ethnic group?

id verification

Please upload a picture of an identification document, such as passport of driver license.

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