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Gynaecology Questionnaire

YesNo
YesNo
YesNo
Date of last period
Do you have pain during sexual intercourse?
YesNo
Do you have any vaginal discharge?
YesNo
When was your last smear test?
Have you ever had an abnormal smear test?
YesNo
Have you ever had any treatment to the cervix?
YesNo
Have you had any gynaecological surgery?
YesNo
If yes, select here
HysterectomyMyomectomyLaparoscopyTubal
Have you had any previous gynaecological problems?
YesNo
If yes, select here
FibroidsCystsEndometriosis
Have you ever had a sexually transmitted infection?
YesNo
If yes, select here
GonorrhoeaChlamydiaTrichomonasSyphilis
How many pregnancies have you had?
How many children do you have?
Have you had any pregnancy complications?
YesNo
If yes, select here
MiscarriagesEctopic pregnanciesTerminations
What contraception do you use?
PillCondomIUDOtherNone