New Patient Health Questionnaire

  • Patient Registration
  • Health Questionare

Patient Registration

Some description about this section

eg. 2000

Contact Details


SMS and Email Correspondence


Emergency Contact


Medicare/Health Fund Details


The 10 digit number on the front of your card.
The number next to your name
eg. 10/2022

Your General Practitioner


Your Referring Doctor


Correspondence will automatically be sent to your referring doctor and copied to your GP. Please inform us if you do not want correspondence sent.

Practice Information

Privacy Notice

The personal and health information that is provided by you and recorded in your Electronic Health Record will be collected for the purpose of providing you with treatment. Your information is collected and held in accordance with NSW privacy legislation under which you have rights of access and correction. More information about your privacy rights is available on the internet at www.privacy.gov.au.

Your medical record is a permanent legal document and we take its security very seriously. We can, on written request, provide you or a person nominated by you with a copy of your Health Record. For legal reasons, your request must be made in writing, and approved by your treating Practitioner.

Consent to Release of Medical Information

I give my consent to Yanada Women’s Health Pty Ltd, or their agent and advisors, to contact medical practitioners or other bodies who I have consulted to obtain health and other information that may be pertinent to my care. I authorize those medical practitioners or bodies to release such information, which may include sensitive health information, to Yanada Women’s Health Pty Ltd, or their agent and advisors, as may be requested. I understand that unless I advise otherwise, Yanada Women’s Health Pty Ltd will continue to liaise with the doctors nominated by me on matters related to my ongoing care.

Cancellation Policy

SMS reminders will be sent for all scheduled appointment 2 working days prior. If you do not have a mobile phone or elect not to receive an SMS, our practice staff will telephone you on the number/s you have provided. If it is necessary to cancel your scheduled appointment, we require that you notify us by 4pm the working day before. This can be done either by responding to the SMS or phoning 02 9134 5853. Any appointment not confirmed by return SMS or phone call by 4pm the working day prior will automatically be cancelled. Late cancellations will be considered as anyone who cancels their confirmed appointment after 4pm the working day before.

Yanada Women’s Health Pty Ltd does not charge any cancellation fees, but we do ask that you inform us if you intend to miss your appointment, so that we can offer it to someone who may need it more urgently.

Research Consent

Your information may be used by Yanada Women’s Health Pty Ltd/or Prince of Wales Private Hospital, to contact you for research or to evaluate by the way of audit, the service and/or medical treatment that you have received. Any information that you provide for the audit or research purposes will not identify you in any way.


Your Acknowledgment


Thank you for taking the time to read this information.

Health Questionare

Please fill in the questionnaire to provide us with detailed medical history in the lead up to your appointment. The information will be sent in an encrypted form to protect your privacy.


YesNo
Have you ever been sexually active
Are you in a current relationship
YesNo
Do you experience pain during intercourse (if applicable)
Have you experienced bleeding after intercourse (if applicable)
YesNo
Are your periods regular (if applicable)
YesNo
Do you consider your periods to be heavy (if applicable)
Are your periods painful (if applicable)
Do you need to take time off from work/study due to your period related symptoms (if applicable)
YesNo
Do you experience bleeding between periods (if applicable)
YesNo
Have you gone through menopause
YesNo
Have you been on any hormone replacement
YesNo
Have you used birth control pills in the past
YesNo
Have you ever been pregnant
Have you ever received fertility treatment
YesNo
Have you experienced any weight loss or loss of appetite in the last few months