| Client ID | Client Name | Contact | Patient History for Department |
| SGH-172465566322336 | TEST DOC CLI | 9579898798 | GYNECOLOGY AND OBSTETRICS |
| INITIAL CLIENT INTERVIEW QUESTIONAIRE | |||
| INITIAL CLIENT INFORMATION FORM 1 | |||
| Partner 1 | Partner 2 | ||
| Full Name | Full Name | ||
| Date of Birth | Date of Birth | ||
| Age Proof (Document Type) | Age Proof (Document Type) | ||
| Proof of Age Uploadation Status | Proof of Age Uploadation Status | ||
| Relationship Status | Relationship Status | ||
| Referred From | |||
| Note for Referred Place | |||
| Resident Of | |||
| Residential Details | |||
| Proof of Marriage (Document Type) | |||
| Proof of Marriage Uploadtion Status | |||
| INITIAL CLIENT INFORMATION FORM 2 | |||
| Any Special Social/Cultural/Religious Preference | Specify Special Social/Cultural/Religious Preference | ||
| Present Complaints | Known Allergies | ||
| Known Allergies Description | Reason for Visiting Us At PETALS | ||
| HISTORY MALE | |||
| DETAILED PERSONAL INFORMATION | |||
| GENERAL INFORMATION | |||
| First Name | Middle Name | ||
| Last Name | MRN | ||
| Identification Marks | Blood Group | ||
| Age | Date of Birth | ||
| Maritial Status | Gender | ||
| Religion | Nationality | ||
| Mobile Number | Telephone Number | ||
| Address | |||
| State | City | ||
| PIN Code | Race / Ethnicity | ||
| EDUCATIONAL AND OCCUPATIONAL QUALIFICATIONS | |||||
| Academic Qualification | Academic Field | ||||
| Occupation | Employee of the Corporate / company | ||||
| JURISPRUDENTIAL INFORMATION | |||
| Address Proof Type | Address Proof No. | ||
| Type of Age Proof | Age Proof No | ||
| Type of Marriage Proof | Marriage Proof Document No | ||
| If not a resident of India | |||
| Passport | VISA | ||
| VISA Catyegory | VISA Validity | ||
| MEDICAL HISTORY | |||
| Chief Complaint | |||
| Emergency Contact | |||
| Have ever had experienced fatherhood from this/ Any Previous Relationship | Refered By (Dr.) | ||
| Life style History | |||
| Diet | Diet Details | ||
| Habit | Habit Details | ||
| Lifestyle Disorder | |||
| History of Chronic Illness | |||
| DM | HTN | ||
| THYROID | HEART DISEASE | ||
| TB | ALLERGY | ||
| ALLERGY Details | Other Medical Incident | ||
| Other Medical Incident Details | |||
| Surgical History | |||
| Surgical History | Date of Surgery | ||
| Name of Surgical Procedure | Notable Complications | ||
| Notable Complications Description | |||
| History of Accidents/ Incidents | |||
| Were you involved in any accidents/incidents resulting in a scrotal injury? | Did you seek a consultant’s advice regarding the same? | ||
| May you summarize the advice given by the consultant? | |||
| Family History |
| Family Member 1 | |||
| Relationship with the Client | Disease | ||
| Type of Disease | Mode of Management | ||
| Nature of Disease | Treatment Status | ||
| Family Member 2 | |||
| Relationship with the Client | Disease | ||
| Type of Disease | Mode of Management | ||
| Nature of Disease | Treatment Status | ||
| Family Member 3 | |||
| Relationship with the Client | Disease | ||
| Type of Disease | Mode of Management | ||
| Nature of Disease | Treatment Status | ||
| Covid History | |||
| Covid History | Date of Diagnosis | ||
| Date of Cure | Mode of Management | ||
| Cause of Hospitalization | Any Known Complications | ||
| Known Complication Description | |||
| GENERAL EXAMINATION |
| GENERAL PROFILE | |||
| Height | Weight | ||
| BMI | Skin Tone | ||
| Hair Colour | Eye Colour | ||
| Physique | Facial Features | ||
| Eye Shape & Contour | Specific Finding | ||
| Are You Differently Abled? | |||
| VITAL SIGNS | |||
| Taken At | Date | ||
| VITAL SIGNS | VALUE | RANGE | REMARKS |
| TEMPERATURE | 97-99°F | ||
| PULSE RATE (RESTING) | 60-100bpm | ||
| BLOOD PRESSURE | 120/95(± 10)mm/Hg | ||
| RESPIRATORY RATE | 12-20 Breath/Min | ||
| SpO2 | 95-100% |
| SYSTEMIC/INTIMATE EXAMINATION | |||
| FOR BOTH | |||
| Female Pallor | Male Pallor | ||
| FOR FEMALE | |||
| BREAST | |||
| P/A | |||
| P/S | |||||
| Cervix | Vagina | Discharge | |||
| P/V | |||||
| Uterus | Size | ||||
| Position | Fornices | Tenderness | |||
| P/R | |||
| P/R | |||
| CNS | |||
| CNS | |||
| CVS | |||
| CVS | Provisional Diagnosis | ||
| FOR MALE |
| Oedema | |||
| Oedema | |||
| PARAMETERS | LEFT SCROTUM | RIGHT SCROTUM | |
| TESTICULAR CONSISTENCY | |||
| TESTICULAR VOLUME | |||
| DUCTUS DEFERENCE | |||
| EPIDIDYMIS | |||
| TESTICULAR TENDERNESS | |||
| Identification Marks | |||
| HISTORY FEMALE |
| DETAILED PERSONAL INFORMATION |
| GENERAL INFORMATION | |||
| First Name | Middle Name | ||
| Last Name | MRN | ||
| Identification Marks | Blood Group | ||
| Age | Date of Birth | ||
| Maritial Status | Gender | ||
| Religion | Nationality | ||
| Mobile Number | Telephone Number | ||
| Address | |||
| State | City | ||
| PIN Code | Race / Ethnicity | ||
| EDUCATIONAL AND OCCUPATIONAL QUALIFICATIONS | |||
| Academic Qualification | Academic Field | ||
| Occupation | Employee of the Corporate / company | ||
| JURISPRUDENTIAL INFORMATION | |||
| Address Proof Type | Address Proof No. | ||
| Type of Age Proof | Age Proof No | ||
| Type of Marriage Proof | Marriage Proof Document No | ||
| If not a resident of India | |||
| Passport | VISA | ||
| VISA Catyegory | VISA Validity | ||
| MEDICAL HISTORY | |||
| Chief Complaint | |||
| Emergency Contact | |||
| Menstrual History | |||
| Menstrual Type | Duration of Flow | ||
| Painful | Flow Type | ||
| Interval | |||
| Obstetric History | |||
| Conception from Present/ Any Previous Relationship | |||
| Fate of Previous Conception | |||
| GRAVIDA | GRAVIDA (Other Details) | ||
| PARA | PARA (Other Details) | ||
| ABORTIONS | ABORTIONS (Other Details) | ||
| LIVE | LIVE (Other Details) | ||
| ECTOPIC | |||
| ECTOPIC (Left Details) | ECTOPIC (Right Details) | ||
| Life style History | |||
| Diet | Diet Details | ||
| Habit | Habit Details | ||
| Lifestyle Disorder | |||
| History of Chronic Illness | |||
| DM | DM Details | ||
| HTN | HTN Details | ||
| THYROID | THYROID Details | ||
| HEART DISEASE | HEART DISEASE Details | ||
| TB | TB Details | ||
| ALLERGY | ALLERGY Details | ||
| Other Medical Incident | |||
| Other Medical Incident Details | |||
| Surgical History | |||
| Surgical History | Date of Surgery | ||
| Name of Surgical Procedure | Notable Complications | ||
| Notable Complications Description | |||
| Family History |
| Family Member 1 | |||
| Relationship with the Client | Disease | ||
| Type of Disease | Mode of Management | ||
| Nature of Disease | Treatment Status | ||
| Family Member 2 | |||
| Relationship with the Client | Disease | ||
| Type of Disease | Mode of Management | ||
| Nature of Disease | Treatment Status | ||
| Family Member 3 | |||
| Relationship with the Client | Disease | ||
| Type of Disease | Mode of Management | ||
| Nature of Disease | Treatment Status | ||
| Covid History | |||
| Covid History | Date of Diagnosis | ||
| Date of Cure | Mode of Management | ||
| Cause of Hospitalization | Any Known Complications | ||
| Known Complication Description | |||
| GENERAL EXAMINATION |
| GENERAL PROFILE | |||
| Height | Weight | ||
| BMI | Skin Tone | ||
| Hair Colour | Eye Colour | ||
| Physique | Facial Features | ||
| Eye Shape & Contour | Specific Finding | ||
| Cause of Hospitalization | Any Known Complications | ||
| Are You Differently Abled? | |||
| VITAL SIGNS | |||
| Taken At | Date | ||
| VITAL SIGNS | VALUE | RANGE | REMARKS |
| TEMPERATURE | 97-99°F | ||
| PULSE RATE (RESTING) | 60-100bpm | ||
| BLOOD PRESSURE | 120/95(± 10)mm/Hg | ||
| RESPIRATORY RATE | 12-20 Breath/Min | ||
| SpO2 | 95-100% |
| ABDOMINAL EXAMINATION |
| OBSTETRIC | |||
| P/A | Tone | ||
| Lie | FHS | ||
| Per Speculum | Per Vaginum | ||
| GYNECOLOGY | |||
| P/A | P/S | ||
| P/V | |||
| BREAST EXAMINATION |
| LEFT SIDE | |||
| Abnormality | Details | ||
| RIGHT SIDE | |||
| Abnormality | Details | ||
| INFORMATION FOR YOUR FERTILITY SPECIALIST | |||
| Previous Conception/s from any Previous Relationship | Fate of Previous Conception | ||
| Congenital Anomalies | Congenital Anomalies Description | ||
| Provisional Diagnosis | Semen Analysis Results | ||
| TVS Findings | AMH Value | ||
| Special Points | Confirmed Diagnosis at PETALS/ NOVA IVF Fertility: proposed treatment cycle | ||
| INFORMATION FOR YOUR GYNECOLOGY & OBSTETRICS SPECIALIST |
| PROVISIONAL DIAGNOSIS | |||
| Adolescent | Maternal & Fetal Medicine | ||
| Adolescent Category | Maternal & Fetal Medicine Category | ||
| If Others | If Others | ||
| Contraceptives | Urogynaecology | ||
| Contraceptives Category | Urogynaecology Category | ||
| If Others | If Others | ||
| Cosmetic | Minimal Access Surgeries | ||
| Cosmetic Category | Minimal Access Surgeries Category | ||
| If Others | If Others | ||
| Gynaecological Conditions | Onco-Gynaecology | ||
| Ovarian Cysts | CA Cervix | ||
| Fibroids | CA Ovary | ||
| Uterine Prolapse | CA Vulva | ||
| Adenomyosis | CA Vagina | ||
| Endometriosis | |||
| Uterine Polyps | |||
| CONFIRMED DIAGNOSIS | |||
| Adolescent | Maternal & Fetal Medicine | ||
| Adolescent Category | Maternal & Fetal Medicine Category | ||
| If Others | If Others | ||
| Contraceptives | Urogynaecology | ||
| Contraceptives Category | Urogynaecology Category | ||
| If Others | If Others | ||
| Cosmetic | Minimal Access Surgeries | ||
| Cosmetic Category | Minimal Access Surgeries Category | ||
| If Others | If Others | ||
| Gynaecological Conditions | Onco-Gynaecology | ||
| Ovarian Cysts | CA Cervix | ||
| Fibroids | CA Ovary | ||
| Uterine Prolapse | CA Vulva | ||
| Adenomyosis | CA Vagina | ||
| Endometriosis | |||
| Uterine Polyps | |||
| COMMENTS SECTION | |||
| Selected Adolescent Category | Selected Maternal & Fetal Medicine | ||
| Provisional | Provisional | ||
| Confirmed | Confirmed | ||
| Selected Contraceptives | Selected Urogynaecology | ||
| Provisional | Provisional | ||
| Confirmed | Confirmed | ||
| Selected Cosmetic | Selected Minimal Access Surgeries | ||
| Provisional | Provisional | ||
| Confirmed | Confirmed | ||
| Special Comments (if any) | |||
| Comments for Male Partner (if any) | |||