COMPLAINT FORM
(Gynaecology Section)

Please tell us about your problems:

(1) Marital Status?
(2) For how long you have been married?
Years Months
(3) At what age your menstruation cycle started?
(4) Is your menstruation cycle regular with moderate bleeding?
Yes No
(5) Do you experience any bleeding between two cycles?
Yes No
(6) Do you experience any pain before or during menstruation?
Yes No
(7) Do you experience any kind of pain during intercourse? 
Yes No
(8) Is there any vaginal discharge?
If yes! please provide information about it?
Yes No

Color Smell

Amount

(9) Have ever been pregnant?
Yes No
(10) What was the out come of each pregnancy?
(11) How many miscarriages and terminations?
(12) have you ever had any complications during or after pregnancy?
Yes No
(13) Are you using any kind of contraception?
If yes! What kind of: 
Yes No
(14) Do you have history of following:
Blood Pressure
Diabetes
Asthma
Tuberculoses
Jaundice
Any Cardiac Problem
Please Check your answer:
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
(15) Any Surgical History?
If yes! What type
Yes No
(16) Description of your complaint

Please provide the following contact information:

Name
Age
Occupation
Phone
FAX
E-mail
Postal Address

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