Group 20
Group 19
Group 19
Group 21

Health Questionnaire

Patient Intake Form
  • Patient Registration
  • Health Questionnaire

Patient Registration

Some description about this section

eg. 2000

Contact Details

SMS and Email Correspondence

We send you a text message (SMS) 2 days before your scheduled appointment as  a reminder.

As a paperless practice, we use email as the preferred mode of communication to send you copies of clinic letters and other treatment related documents. Your email address will not be published. 

Please speak to the practice staff if you do not wish to receive email communications or SMS appointment reminders.


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. For more information please read our practice privacy policy.

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

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.

For more information please read the practice Terms and Conditions

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 Questionnaire

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.

Have you ever been sexually active
Are you in a current relationship
Do you experience pain during intercourse (if applicable)
Have you experienced bleeding after intercourse (if applicable)
Are your periods regular (if applicable)
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)
Do you experience bleeding between periods (if applicable)
Have you gone through menopause
Have you been on any hormone replacement
Have you used birth control pills in the past
Have you ever been pregnant
Have you ever received fertility treatment
Have you experienced any weight loss or loss of appetite in the last few months

Have a question?