Consultation Form Your name (full)(Required) Email(Required) Address(Required) Phone(Required)Age(Required)Date of birth(Required) MM slash DD slash YYYY GP(Required) Reason for getting in touch with Lynda at Lady Talk(Required)Do you have any of the following:Untreated liver disease(Required) Yes No Personal risk of breast cancer(Required) Yes No Thrombophilia (increased tendency to form blood clots)(Required) Yes No Undiagnosed vaginal bleeding(Required) Yes No Migraines(Required) Yes No Untreated high blood pressure(Required) Yes No Established cardiovascular disease(Required) Yes No Genitourinary and Pelvic Floor Symptoms Pain during sex Vaginal dryness Feelings of heaviness or dragging between the legs Changes to the vulval area Unexplained itching Unexplained discharge or odor Unexplained vaginal bleeding Rectal bleeding or haemorrhoids Not making it too the loo on time Leaking of urine when you sneeze, jump, cough or laugh Constipation or straining on the loo Revelant Gynaecological Conditions History of endometriosis Previous Hysterectomy Surgical menopause Polycystic ovarian syndrome Premature ovarian insufficiency Early menopause < 45 years Other Gynae Surgery What medical checks have you had:Health checks up to date?(Required) Yes No Has your blood pressure been taken recently?(Required) Yes No Cervical screening?(Required) Yes No Unsure Mammograms?(Required) Yes No Unsure Molemaps/skin checks?(Required) Yes No Unsure Blood pressure (Lynda will take this when you see her)Pulse (Lynda will take this when you see her)Weight (kg)(Lynda will take this when you see her)Current Medications Add RemoveCurrent injuries/medical conditions/major surgery – please list Add RemovePlease rate the following from 1 (not that happy) - 10 (managing this very well)Sleep(Required)Please enter a number from 1 to 10.Stress(Required)Please enter a number from 1 to 10.Nutrition(Required)Please enter a number from 1 to 10.Social Activity (healthy regular relationships with others)(Required)Please enter a number from 1 to 10.Substance use (are you happy about smoking, your alcohol intake or drug use?)(Required)Please enter a number from 1 to 10.Exercise(Required)Please enter a number from 1 to 10.Pelvic HealthLast Menstrual period(Required) Mirena(Required) Yes No Current contraception(Required) Perimenopausal symptoms Add RemoveGynaecology history (Hysterectomy, Gynae surgery/conditions)Live births (Include dates and Normal vaginal delivery NVD or Lower Segment Caesarean Section LSCS)Pregnancies(Required)How often do your bowels open?(Required) 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) Yes No
