PERSONAL INFORMATION	Name
     	Date of birth
     	
SEXUAL AND REPRODUCTIVE HEALTH
	The age of first menstruation

       years	Length of menstrual cycle 
(from the first day of menstrual bleeding, to the beginning of the next)
       days	Duration of the menstrual bleeding

       days	
	Last menstrual cycle started at, date
     	Menstrual pains
 no    yes	
	Do you take pain medication, which, daily dosage, does it help?
     	
	Menstrual bleeding 
 light    normal    heavy 	
CONTRA-CEPTION	Have you had sexual intercourse?
 no    yes	The age of first intercourse
       years	
	Have you previously used
 pills   ring   patch   capsule   intrauterine contraceptive (IUC) with progestogen   Copper IUD	
	Which (name of the brand, if you can remember), when, did the product suit you well?
     	
	Have you had any unprotected intercourse?
 no   yes	Have you used emergency post-coital contraception?
 no    yes

      times, last       
	
PREGNANCIES AND GYNAECO-LOGICAL DISORDERS	Births	No  	Yes  	Year	
	vaginal delivery	 	 	     	
	caesarean section	 	 	     	
	Any abnormalities during pregnancy or deliveries?
     	
		No  	Yes  	Year	What treatment did you receive?	
	Miscarriages			     	     	
	Abortions			     	     	
	Ectopic pregnancy			     	     	
	Other gyn. disorders/operations			     	What?
     	
	STD
			     	What?
     	
EXAMINATIONS		No  	Yes  	Year		
	Pap smear			     	Result
     	
	Pap changes		 	     	What, was a procedure carried out (for example, Loop treatment)?
     	
	Gynaecological examination			     		
	Do you examine your breasts regularly?
 no   yes	
SMOKING/
INTOXICANTS		No  	Yes  	Amount	/day	/week	/month	
	Smoking/snuff			       cigarettes/times	 	 	 	
	Alcohol			        portion/times	 	 	 	
	Drugs, other substances			Which, amount?
     
/times	 	 	 	
	Turn   ®	
		
HEALTH INFORMATION	Illness / symptom	No 	Yes 	Medication / care unit	
	Acne	 	 	     	
	Allergies 
(also medication), asthma	 	 	     	
	Diabetes	 	 	     	
	Epilepsy	 	 	     	
	Liver illness, 
for example, hepatitis	 	 	     	
	Mental health
(for example, depression, anxiety, panic disorder, eating disorder)	 	 	     	
	Migraine	 	 	     	
	Visual or sensory symptoms (with aura)				
	Propensity to thrombosis or haemophilia	 	 	If yes, have more throughout examinations been carried out, what, when and what were the results?
     	
	Hypertension	 	 	     	
	Other, for example, propensity to anaemia, operations	 	 	     	
	Any regular medication, if not mentioned above	
	Drug, dosage
     	Reason for the medication
     	
ILLNESSES IN CLOSE FAMILY (parents, siblings, grandparents)	Do any of the following illnesses appear or are they suspected in your family 	No	Yes	Who, at what age?	
	Propensity to thrombosis or haemophilia	 	 	     	
	Deep vein thrombosis, pulmonary embolism or stroke 	 	 	     	
	Heart attack	 	 	     	
	Hypertension	 	 	     	
	Cancer (especially breast, ovarian or colorectal cancer)	 	 	     	
	Other significant illness	 	 	     	
SEXUAL WELLBEING	Have you experienced any sexual harassment or violence or other kind of violence?	 no	 yes	
	Do you have any questions concerning sexuality or romantic relationships?	 no	 yes	
Please write down any issues you would like to discuss
     	

Thank you!