Female Patients Form 1

YES NO

DOCTOR ONLINE DOCTOR PHARMACY NEVER PRESCRIBED If other, please specify:

MORE THAN 12 MONTHS LESS THAN 12 MONTHS

YES NO REGULARLY IRREGULAR MISSED PERIODS SIGNIFICANTLY IRREGULAR PERIODS If other, please specify:

NO YES, THERE WAS, please specify:

NO YES YES, THERE WAS, please specify:

NO YES YES, I AM, please specify:

NO YES, I WAS, please specify:

NO YES, I HAVE, please specify:

NO YES, I HAVE, please specify:

NO YES

FEMALE MALE

YES NO

YES NO

NO YES

NO YES CASUAL SMOKER (Less than a pack a year)

YES NO

NO YES, I HAVE, please specify:

NO YES, I HAVE, please specify:

NO YES, I HAVE, please specify: Type 1 or Type 2

NO, I'VE NOT YES, I HAVE, please specify:

NO YES

NO YES, I HAVE, please specify when:

I NEVER had a cervical smear NORMAL ABNORMAL

NO YES, THERE IS, please specify:

NO YES, THERE IS, please specify:

NO YES, THERE IS, please specify:

NO YES, I HAVE, please specify:

NO YES, I AM, please specify:

NO YES, I HAVE, please specify:

I CONFIRM I DO NOT CONFIRM