Consultation Form

MM slash DD slash YYYY

Do you have any of the following:

Untreated liver disease(Required)
Personal risk of breast cancer(Required)
Thrombophilia (increased tendency to form blood clots)(Required)
Undiagnosed vaginal bleeding(Required)
Migraines(Required)
Untreated high blood pressure(Required)
Established cardiovascular disease(Required)
Genitourinary and Pelvic Floor Symptoms
Revelant Gynaecological Conditions

What medical checks have you had:

Health checks up to date?(Required)
Has your blood pressure been taken recently?(Required)
Cervical screening?(Required)
Mammograms?(Required)
Molemaps/skin checks?(Required)
(Lynda will take this when you see her)
(Lynda will take this when you see her)
(Lynda will take this when you see her)
Current Medications
Current injuries/medical conditions/major surgery – please list
Please rate the following from 1 (not that happy) - 10 (managing this very well)
Please enter a number from 1 to 10.
Please enter a number from 1 to 10.
Please enter a number from 1 to 10.
Please enter a number from 1 to 10.
Please enter a number from 1 to 10.
Please enter a number from 1 to 10.

Pelvic Health

Mirena(Required)
Perimenopausal symptoms
If there is anything private that you would like to discuss that you don’t feel comfortable writing on a form, please let us know and we will cover this in our consultation(Required)