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AGORA SPECIALIST CENTRE
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Patient Forms
Dr FATIMA KHAN HORMONAL QUESTIONNAIRE
DR FATIMA KHAN HORMONAL QUESTIONNAIRE
BASIC INFORMATION
Full Name
*
First Name
Last Name
Mobile Phone
*
Regular GP
Age
*
Occupation
*
Martial Status
*
Number Of Children
*
Age Of Children
Height (cms)
*
Weight (kgs)
*
Blood Pressure
*
Please record the date and value of your most recent blood pressure reading (if you do not know the value, please write unknown)
HORMONE THERAPY / CONTRACEPTION
Are you currently using or have you used Hormone Therapy (HRT)?
*
Yes
No
If yes, please specify
Are you currently using contraception?
*
Yes
No
If yes, please specify
Describe your menstrual cycle
*
Include duration, frequency and bleeding pattern. If you no longer have a cycle, please record the approx date it ceased.
HORMONAL SYMPTOMS
Tick if you have any of the following symptoms
*
Hot Flushes
Night Sweats
Sleep Disturbance
Headaches
Joint Aches
Mood Changes
Forgetfulness
Unable To Focus/Concentrate
Low Energy
Skin Changes
Facial Hair
Hair Loss
Vaginal Dryness
Low Libido/Sexual Desire
Uncomfortable Sexual Intercourse
PERSONAL HISTORY
List any medical problems that other doctors have diagnosed
Include the year diagnosed
Have you had a blood clot in the past?
*
If so, please list date and details
Have you ever had breast cancer?
Please include details and diagnosis year
List any surgeries / hospitalisations
Include reason, hospital name and year
List any drug allergies and reactions you have had
List your current prescribed medications
Include name of medication, strength and frequency taken
List any over-the-counter medications / vitamins / herbs
LIFESTYLE
Are you a current smoker?
*
Yes
No
If so, how many per day?
Do you consume alcohol?
*
Yes
No
If so, how many standard drinks and how often?
How often do you exercise?
*
What type of exercise do you do?
Describe your eating habits
*
How would you rate your diet?
*
Poor
Average
Excellent
How would you rate your stress levels?
*
Low
Average
High
SCREENING
When was your most recent mammogram?
*
When was your most recent cervical screen (previously called pap smear)?
*
Have you had a bone density scan (DEXA)?
*
FAMILY HISTORY
List any significant family medical history
Include relation, health problem and age diagnosed (if known)
Would you like correspondence from your consultation with Dr Khan to be sent to your GP?
*
Yes
No
How did you hear about Dr Fatima Khan?
Today's Date
*
Thank you!
Hospital Admission Forms
epworth richmond hospital admission form
online form
frances perry hospital admission form
Online Form
