Dr Peterson & Dr Allen Reproductive Health Form

Dr Peterson & Dr Allen Reproductive Health Form

Complete health assessment and information.

Patient Details
Please select a title
Surname is required
Given names are required
Please enter a valid date (DD/MM/YYYY)
Age must be between 1 and 100
Residential address is required
Post code must be 4 digits
Mobile phone is required
Please enter a valid email address
General Information
Reason for visiting is required
Please tell us how you heard about this service
Insurance & Card Details
Medicare number must be 10 digits
Reference number must be between 1 and 10
Please enter a valid date (DD/MM/YYYY)
Please enter a valid date (DD/MM/YYYY)
Please enter a valid date (DD/MM/YYYY)

Patients are responsible for all account payments. If you are unable to attend an appointment we would appreciate at least 24 hours' notice so that another patient may benefit from this time. If you cancel on the day of your appointment a non-attendance fee of $60-00 (30 minute consult) or $30-00 (15 minute consult) will apply. If you miss an appointment without notice, you will be charged the full fee. These fees are not claimable through Medicare.

I am responsible for the full amount fees and I declare that the above information to be true and correct.

You must agree to the terms and conditions
Emergency Contacts
Next of kin name is required
Relationship is required
Phone number is required
Cultural & Other Information
Please select at least one option.
Please select at least one option.
Medical History
Current health issues are required

Note: Please bring in a copy of your health history information for the past 6 months.

Social and Lifestyle History
Please select at least one option.
Please select at least one option.
Please select at least one option.
Please select at least one option.
Pregnancy History
Year Outcome (birth/miscarriage/induced abortion)
Family History

Please include history of heart problems, thyroid issues, diabetes, cancers, high blood pressure, depression and anxiety, bone and joint problems, menstrual, pregnancy problems, other

General Past History
Gynaecological History
Menstrual History
Family Fertility History
For Women Only
History of Fertility Tests, Procedures and Treatments
Test Y/N Details
Day 21 progesterone
Semen Analysis
AMH
Ultrasound Pelvis/Follicles
Other
Fertility Procedures
Procedure Y/N Details
HSG (Hysterosalpingogram or tube studies)
Hysteroscopy
Laparoscopy
Other
Fertility Medical Treatments
Medical Treatments Y/N Dates (approx.)/Details
Contraceptive pills
Mirena
Implanon
Clomid or Serophene
Injectable Hormone Treatment
ART Treatments
IVF
ICSI
GIFT
ZIFT
Artificial Insemination – Intrauterine (IUI)
Husband (AIH)
Donor (AID)
Other
Fertility Surgical Treatments
Treatment Y/N Details
Cervix Surgery
Uterine Surgery
Ovarian Surgery
Tubal Surgery
Other
Relationship History
Please select your relationship status
PMS Screening Questionnaire

PMS is often a marker of hormonal abnormality so it is very relevant to your assessment. Please indicate symptoms you experience at least 4 days before your menstrual period that are relieved within the first couple of days of your period and have been present in at least 3 out of the past 6 cycles.

Severity Scale: 0 = none, 1 = mild (doesn't interfere), 2 = moderate (interferes but not disabling), 3 = severe (disabling)

Symptom
Severity (0-3)
# Days
DASS-21 Assessment *

Instructions: Please read each statement and select a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

Rating Scale:

  • 0 - Did not apply to me at all
  • 1 - Applied to me to some degree, or some of the time
  • 2 - Applied to me to a considerable degree, or a good part of time
  • 3 - Applied to me very much, or most of the time
1. I found it hard to wind down
Please select at least one option.
2. I was aware of dryness of my mouth
Please select at least one option.
3. I couldn't seem to experience any positive feeling at all
Please select at least one option.
4. I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion)
Please select at least one option.
5. I found it difficult to work up the initiative to do things
Please select at least one option.
6. I tended to over-react to situations
Please select at least one option.
7. I experienced trembling (eg, in the hands)
Please select at least one option.
8. I felt that I was using a lot of nervous energy
Please select at least one option.
9. I was worried about situations in which I might panic and make a fool of myself
Please select at least one option.
10. I felt that I had nothing to look forward to
Please select at least one option.
11. I found myself getting agitated
Please select at least one option.
12. I found it difficult to relax
Please select at least one option.
13. I felt down-hearted and blue
Please select at least one option.
14. I was intolerant of anything that kept me from getting on with what I was doing
Please select at least one option.
15. I felt I was close to panic
Please select at least one option.
16. I was unable to become enthusiastic about anything
Please select at least one option.
17. I felt I wasn't worth much as a person
Please select at least one option.
18. I felt that I was rather touchy
Please select at least one option.
19. I was aware of the action of my heart in the absence of physical exertion (eg, sense of heart rate increase, heart missing a beat)
Please select at least one option.
20. I felt scared without any good reason
Please select at least one option.
21. I felt that life was meaningless
Please select at least one option.
Privacy Authorisations

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Please sign above
Patient signature is required

By submitting this form, you consent to the collection and processing of your personal information in accordance with our privacy policy.