APPENDIX 9.1 - ANAMNESIS FORM

GYNAECOLOGICAL ANAMNESIS

HISTORY OF FORMER PREGNANCIES

YEAR	DELIVERY	STILLBIRTH	SP . AB	A.A.P.

Date of LMP: ...........................certain / uncertain Amenorrhoea:

Do you loose much blood during your periods:

Symptoms suggesting threatening abortion:

Symptoms suggesting ectopic pregnancy:

(Hyper)emesis gravidarum:

History of gynaecological operations (Caesars, fibromectomy, ectopic, adnex operations):

History of cervical operations (cauterisation, conisation, amputation, Shirodkar):

GENERAL ANAMNESIS

Do you or one of your family members suffer from one of the following diseases:

Diabetes:

 

Epilepsy:

 

Sickle cell anaemia:

Are you allergic for anything:

Did you ever have a problem after getting local anaesthesia (also dentist):

Are you under anticoagulant treatment:

REMARKS

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