Pre-Consultation Medical Questionnaire EN

Ce champ n’est utilisé qu’à des fins de validation et devrait rester inchangé.

1. Personal Information

Please complete all required personal information.
First and Last Name(Nécessaire)
JJ slash MM slash AAAA

2. Requested Consultation Type

Requested Consultation Type(Nécessaire)
Preferred Consultation Schedule(Nécessaire)
Request for an urgent appointment or a consultation outside standard hours (subject to availability and possible additional fees).

3. Reason for Consultation

Please describe the reason for your consultation, the main symptoms, when they started, how they have evolved over time, what they are associated with, and which factors aggravate or relieve them.

4. Personal Physiological History

Age at first menstruation, whether menstrual cycles became regular during the first year after onset, current menstrual cycle characteristics, cycle length, duration of menstruation, whether periods are heavy or painful, and any associated symptoms.abundente sau dureroase și dacă sunt însoțite de alte simptome.
Age at first sexual intercourse, presence of a stable partner, current sexual activity, discomfort or pain during sexual intercourse, bleeding after intercourse, and any history of genital infections or sexually transmitted infections.
Current or previous contraceptive methods, tolerance of hormonal contraception, and any side effects or complications.
Number of pregnancies, deliveries, vaginal deliveries, cesarean sections, spontaneous or induced abortions, ectopic pregnancies, pregnancy complications, and any infertility treatments.infertilitate.
Menopause or perimenopause, age at menopause onset, associated symptoms, hormonal treatments used, and evolution of symptoms over time.
Height, weight, physical activity, dietary habits, possible occupational exposures, work-related stress, work schedule, smoking, alcohol consumption, other habits, known allergies, and any other important lifestyle-related information.

5. Family History

6. Personal Medical History

Treatment currently taken for chronic diseases or other medical conditions, including hormonal therapies, regular medications, and dietary supplements.

7. Medical Documents

Laboratory tests, ultrasound examinations, MRI/CT scans, HPV/Pap smear results, medical reports, operative reports, histopathology results, or any other relevant medical documents.
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Taille max. des fichiers : 8 MB.
    Please upload all available relevant medical documents. They must be submitted at least 48 hours before the selected consultation time.

    8. Consent and Confirmation

    I confirm the following:(Nécessaire)