Medical history form | LifeCycle Clinic

First name

Last name

Address

Birthday

Age at first period

How many pregnancies have you had?

How many vaginal deliveries / instrumental deliveries / caesarean sections?

Have you had any miscarriages or ectopic pregnancies?

Are you using any contraception at present?

Have you used any contraception in the past?

Have you ever had an STI eg. chlamydia, gonorrhoea, herpes, genital warts?

Do you smoke, and if so, how many a day? Or are you an ex-smoker?

How many units of alcohol do you drink a week?

Do you have any of the following medical conditions? Check all that apply

Do you take any prescription medications or over the counter medications or supplements?

Do you have any allergies?

Briefly, what is your main reason for coming to see us?