Adolescent Gynae Questionnaire

4/125 Flockton Street, Everton Park, QLD 4053

(07) 3472 9108

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Adolescent Gynae Questionnaire

16 October 2024

"*" indicates required fields

First Name*

Last Name*

Preferred First Name?

Age*

What are your main concerns you would like to discuss?*

MENSES HISTORY

This section is for adolescents to complete whom have started their periods. If you haven't started your period yet, please answer no and you can move to the next section.

Have your periods started?*

Yes

No

If so, when?

When was the start of your last period?

How long does your period typically last?

How long is your cycle length?

Are your periods heavy?

Yes

No

If yes, how many days is your period heavy for?

How often do you change a pad/tampon/cup/underwear on your heavy days?

Do you experience pain with your period?

Yes

No

Do you suffer from pelvic pain when you don't have your period?

Yes

No

Have you tried any previous treatments for any abnormal periods?

HEALTH/SOCIAL HISTORY

Do you have any concern regarding your breast development?*

Yes

No

Maybe

Are you concerned regarding abnormal discharge?*

Yes

No

Are you currently in a relationship?*

Yes

No

Have you had any previous gynaecology problems?*

Yes

No

If yes, can you describe this further

Do you have any other medical conditions?*

Yes

No

If yes, please describe

Do you suffer from anxiety or depression?*

Yes

No

Can you list all specialists and health professionals that you see:

Click on the + symbol to add to the list

Have you had any surgery in the past?*

Yes

No

If yes, please describe

Please list any current medications you take regularly, when needed, complimentary or herbal? (if listed on your GP referral no need to complete here)

Click on the + Symbol to add to the list

Please list any Allergies ( if no allergies, please write - "No Known Allergies"*

Were you born at full term? (40 weeks)*

Yes

No

Did your mother have any problems during her pregnancy?*

Yes

No

Did you have any problems with your development when you were a child?*

Yes

No

Have you had all your childhood vaccinations?*

Yes

No

Did you have your booster and Gardasil (HPV) vaccine in Year 7 ?*

Yes

No

Do you smoke or vape?*

Yes

No

Do you drink alcohol?*

Yes

No

Do you have any family history of medical conditions?

(07) 3472 9108

4/125 Flockton Street, Everton Park, QLD 4053

Services

Contraception
Endometrial Ablation
Hysterectomy
Hysteroscopy
Laparoscopy
Paediatric & Adolescent Gynaecologist (PAG)

Conditions

Abnormal CST
Endometriosis
Fibroids
Heavy Menstrual Bleeding
Incontinence
Menopause
Painful Periods
Polycystic Ovarian Syndrome (PCOS)
Polyps
Ovarian Cysts
Vaginal Prolapse

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