PERSONAL DATA

First name, surname

Date of birth or social security number

Address

Phone number

E-mail address

GENERAL INFORMATION

Height

cm

Weight

kg

Allergies

Current medications

Other medicines, vitamins or natural supplements

GYNECOLOGICAL HISTORY

Age at the first menstrual period

Duration of your menstrual cycle (from first day of menstruation until the the first day of your next menstrual period)

Bleeding days

Do you experience any menstrual pain?

First day of your last menstrual period

Births, years

Miscarriages, ectopic pregnancies, years

Abortions, years

Gynaecological operations, years

Previous PAP test performed

Do you use any contraceptives? Which?

PAST MEDICAL HISTORY

Chronic diseases (diabetes, asthma, gastritis, high blood pressure, bowel diseases, repeated respiratory infections, kidney/liver diseases)

Infectious diseases (HIV, B-, C-hepatitis)

Genital infections (chlamydia, gonorrhea, syphilis etc)

Operations, years

LIFESTYLE

Smoking habits: number of cigarettes a day

Portions of alcohol (by week or by month)

Use of drugs. Which ones?

COVID-19

Have you had coronavirus disease? When?

Have you had a vaccine against coronavirus? When?

Which vaccine did you receive?

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