Skip to Content

(07) 3163 7424

enquiries@baysideog.com.au

Home
About Us
Facilities
Services
Patient Forms
Memories
Contact Us

Obstetrics Form

Please ensure our team have your completed forms prior to your appointment with us.

Javascript is disabled

Javascript is disabled on your browser. Please enable it in order to use this form.

Loading

Obstetrics & Gynaecology Form

Patient Personal Details

Title*

First Name*

Last Name*

Date of Birth*

Select Date ×

Email address*

Phone Home*

( )

Phone Work

( )

Mobile*

Street Address (including postcode)*

Occupation*

Next of Kin/Partner*

Relationship *

Contact Number*

COVID VACCINE

COVID VACCINE

Yes

No

HEALTHCARE COVER

Medicare No:*

Ref No:*

Medicare Expiry:*

Select Date ×

Pension No:

DVA No:

Pension Expiry:

Select Date ×

DVA Expiry:

Select Date ×

Do you have current Private Health Insurance Cover?*

Yes

No

Private Health Insurance Membership No:

Have you held your Hospital cover with your Private Health Fund for more than 12 months?

Yes

No

Does your Private Health Fund Insurance cover you for Obstetrics?

Yes

No

Does your Private Health Insurance cover you for Mental Health Services?

Yes

No

If you are anticipating hospitalisation and / or surgery. Please check full details of your health cover with your Private Health Insurance Company

PERSONAL MEDICAL HISTORY:

Please answer Yes or No if you have any of the following medical problems.

Heart Disease*

Yes

No

Kidney Disease*

Yes

No

Intestinal Problems*

Yes

No

DVT (Blood Clots)*

Yes

No

Anorexia/Bulimia*

Yes

No

Hepatitis *

Yes

No

Tuberculosis *

Yes

No

Mitral Valve Prolapse*

Yes

No

Endometriosis *

Yes

No

Uterine Fibroids*

Yes

No

Blood Transfusions*

Yes

No

Diabetes*

Yes

No

Seizures *

Yes

No

High Cholesterol*

Yes

No

Vision or Hearing Impairment*

Yes

No

High Blood Pressure*

Yes

No

Arthritis *

Yes

No

Migraines *

Yes

No

Breast Problems*

Yes

No

Sexually Transmitted Disease*

Yes

No

Thyroid Disease*

Yes

No

Jehovah Witness*

Yes

No

Heart Murmurs*

Yes

No

Skin Disorders*

Yes

No

Jaundice (yellowing of the skin)*

Yes

No

Depression/Anxiety*

Yes

No

Asthma *

Yes

No

Cancer *

Yes

No

Anaemia/Blood Disease *

Yes

No

Urinary Tract Infection*

Yes

No

History of Ectopic Pregnancy*

Yes

No

Osteoporosis *

Yes

No

FAMILY HISTORY:

Please place a tick in the box of the blood related relatives that have the following.

Diabetes*

Mother

Father

Brother

Sister

Grandparents

N/A

Heart Disease*

Mother

Father

Brother

Sister

Grandparents

N/A

High Blood Pressure*

Mother

Father

Brother

Sister

Grandparents

N/A

DVT (Blood Clots)*

Mother

Father

Brother

Sister

Grandparents

N/A

Cancer*

Mother

Father

Brother

Sister

Grandparents

N/A

CURRENT MEDICATIONS:

Please list all Medications & Dosage you are currently taking.

ALLERGIES:

Please list all Medications from which you have had an allergic reaction.

PREVIOUS SURGERY

Year

Year

Year

Surgery

Surgery

Surgery

GYNAECOLOGICAL HISTORY:

1. Menstrual History:

How old were you when periods first started?*

Do you have cramping or pain with your period?*

How many days apart are your periods?*

How heavy is your period flow generally?*

How many days does your period last?*

Are you having problems with your period?*

2. Pap Smear History:

When was your last pap smear?*

Was it normal?*

Have you ever had an abnormal pap smear?*

If YES, what was done?

3. Breast History

Have you ever had any breast problems?*

When did you last have a mammogram?*

Have you ever had an abnormal mammogram?*

OBSTETRICAL HISTORY:

How many times have you been pregnant?*

How many children do you have?*

Child 1

Month & Year Of birth

Delivery Type

Name

Gestational Age

Weight

Remarks

Labour

Sex

Child 2

Month & Year Of birth

Delivery Type

Name

Gestational Age

Weight

Remarks

Labour

Sex

Child 3

Month & Year Of birth

Delivery Type

Name

Gestational Age

Weight

Remarks

Labour

Sex

SOCIAL HISTORY:

Marital Status:*

Single

Divorced

Married

De Facto

Widow

Partners Name

Partners DOB

Select Date ×

Vasectomy:

Partners Occupation

Do you smoke?*

How many per day?

Are you currently sexually active?*

Are you currently using any type of birth control?*

Consent & Release Of Medical Information

I give consent to Bayside Obstetrics & Gynaecology to contact any of my previous medical practitioners or hospitals to obtain previous health records that are relevant to my current care. Website page is: www.baysideog.com.au and Facebook page is: facebook.com/BaysideOG I authorise those previous practitioners and hospitals to release such information, even sensitive health records, to Bayside Obstetrics & Gynaecology as requested.

How did you hear about us?*

GP Referral

Website / Google

Cinema Advert

Facebook

Referred by a friend

I understand that during my consultation it may be necessary for minor procedures to be performed and I consent to those procedures being carried out after suitable consultation with myself.

Patient Signature

Date*

Select Date ×

Your form has been submitted successfully.

Thank you for completing our form online.
We have received your submission and will be in contact with you shortly.

Server Side Error

We faced problems while connecting to the server or receiving data from the server. Please wait for a few seconds and try again.

If the problem persists, then check your internet connectivity. If all other sites open fine, then please contact the administrator of this website with the following information.

TextStatus: undefined
HTTP Error: undefined

Processing your request

Error

Some error has occured.

Call Us

Email Us

enquiries@baysideog.com.au

Locate Us

Visit our Clinic

Bayside Obstetrics & Gynaecology specialise in a range of professional health services for patients of all ages. More about us.

Facebook
Instagram

CONTACT US

Suite 15, Level 1
Mater Health Centre
16 Weippin Street
Cleveland QLD 4163

Monday to Friday:
8.00am - 5.00pm

PHONE

EMAIL

enquiries@baysideog.com.au

Services

Obstetrics
Gynaecology
Paediatrics
Midwifery
Other

Bayside Obstetrics & Gynaecology 2024. All rights reserved. | Web design by DigitUX™