Dr. Preeti Tandon
(Specialist Obstetrics & Gynaecology Laparoscopic & Robotic Surgeon. )

MBBS, MD(Obs/Gynae), F.MAS(Laparoscopic Surgeon), FICOG
Diploma in Adv Gynae Endoscopy (France), Certified Robotic Surgery Training (USA).

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Patient Questionnaire

Name : DOB :


Nationality : What is patient’s age? When was the last menstrual period?



What are her complaints? Are periods regular? What is the pattern? Is flow in periods normal or heavy?



Does she have children, if yes how many? How old is the youngest child?   Did she have any miscarriages if yes, then at how many weeks of pregnancy?


Does she desire future child bearing?   Is she suffering from any medical illness? Please provide details.


Is she on any medication? Please provide details.   Has she had any surgeries in the past, if yes please provide details?


 
Is there any family history of medical problems?   Is there any h/o cancer in family?


 
Please attach recent imaging or relevant lab reports .