Medical Form - Clinique Fémina

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Terms and conditions*

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Femina Medical Clinic - 1265 rue Berri, office 430, Montreal, Quebec H2L 4X4
(hereinafter called the Clinic)

I hereby certify that I have read and fully understood the risks, restrictions, conditions and instructions for use of the chosen Electronic Communication Services (e-mail and text message, hereinafter referred to as Services) and a full description of which can be found at appendix to this consent form. I understand and accept the risks listed in the appendix to this form that are associated with the use of the Services in the context of communications with the Clinic or members of its staff.
I agree to the conditions and will comply with the instructions listed in the appendix, as well as any other measure that the Clinic may impose in relation to communication with persons using the Services. I acknowledge and understand that despite the recommended use of encryption software as a system to secure electronic communications, it is possible that communications with the Clinic or members of its staff using the Services, may not be encrypted. I agree, however, in full knowledge of the risks, to communicate with the Clinic and the members of its staff by means of these Services.

The transmission of your questionnaire will be done by email on behalf of the Clinique médicale Fémina, via the orchestrator of the website managed by SFR.
The collection of information is made in order to optimize your medical appointment.
Only the employees and physicians of the Clinique médicale Fémina will have access to this information.
Required information is marked with an asterisk.
If you do not wish to complete the questionnaire online, it will be possible to complete it on paper at the clinic.

ANNEX :
Risks associated with the use of an electronic means of communication:
• The Clinic will use reasonable means to protect the security and confidentiality of information sent and received through the Services.
• However, due to the risks mentioned below, the Clinic cannot guarantee the security and confidentiality of electronic communications.
• The use of electronic communications to discuss sensitive information may increase the risk of such information being disclosed to third parties.
• Despite reasonable efforts to protect personal information and ensure the security of electronic communications, it is not possible to completely secure this information.
• Employers and online services may have a legal right to inspect and preserve electronic communications received and transmitted by their system.
• Electronic communications may introduce malicious software into a computer system which could damage or disrupt the operation of the computer, computer network or security systems.
• Electronic communications may be rerouted, intercepted, broadcast, stored or even altered without the Clinic or Patient's knowledge or authorization.
• Even if the sender and recipient have deleted the e-mail messages, there may be backup copies on a computer system.
• Electronic communications may be disclosed pursuant to a reporting obligation or court order.

Using email or text messages as a means of electronic communication carries the following additional risks:
◦ Emails and text messages can be easily re-routed, increasing the risk of being unintentionally sent to an unknown recipient.
◦ It is easier to forge an email and a text message than a handwritten or signed document.
◦ Furthermore, it is impossible to verify the identity of the sender or to ensure that only the recipient will be able to read the email once it is sent.

Conditions of use of the Services:
◦ The Clinic is not responsible for the loss of information caused by technical failures related to the patient's software or internet service provider.

Instructions for Communicating Through the Services
The patient who communicates with the Clinic through the Services must:
• Avoid as much as possible using a computer belonging to your employer or a third party.
• Inform the Clinic of any change made to their email address, cell phone number or any information required for the use of the Services.

If the Services include email and text messages, the patient must:
• Proofread all electronic communications before sending them to the Clinic to ensure that messages are clear and contain all relevant information.
• Take the precautions required to respect the confidentiality of electronic communications, such as using a screen saver and protecting passwords.

Date on which you complete this questionnaire*

Appointment date (if you do not have an appointment, please contact us to schedule one)*

Time of your appointment*

You are covered by*

Quebec Health Insurance (RAMQ)

Interim Federal Health Program (IFHP)

No coverage

Health insurance number (RAMQ)*

Expiration date*

Interim Federal Health Program (IFHP)*

Identification*

First Name Last Name

Gender - used pronoun

Date of birth*

Address*

Postal address Apartment City Province Postal code Country

Phone (mobile)

Phone (home - landline)

E-mail*

Telephone/Fax number of your pharmacy (or the one of your choice for sending prescriptions)*

Occupation

Referred by

Gynecological history

What is the first day of your last period?*

Do you have an appointment for an abortion or for a curettage following a stopped pregnancy?*

Yes

Have you had any bleeding since your last period?*

Yes

When? What quantity?*

Have you taken a pregnancy test?*

Yes

Date*

Result*

Positive

Negative

Date

Result

Positive

Negative

Have you done an ultrasound?*

Yes

Date

Result (number of weeks)

Do you have any pregnancy symptoms?

Yes

Nausea?

Yes

Since when

Frequent urination?

Yes

Since when

Tiredness?

Yes

Since when

Swollen breasts?

Yes

Since when

Have you ever had a gynecological exam with a speculum performed by a doctor or nurse?*

Yes

Are your periods regular ?*

Yes

Why ?

I have a hormonal IUD (Mirena or Kyleena) or an implant (Nexplanon)

I am taking a birth control solution in continuous use (pill, patch or ring)

I am perimenopausal

I have PCOS

Other

How long is your menstrual cycle (number of days between periods)?*

How many days on average does your period last?*

Do you bleed:*

Heavily

Normally

Lightly

Do you have strong cramps during your periods?*

Yes

Do you use painkillers?

Yes

Which ones?

Have you given birth before?*

Yes

Date*

Caesarean?*

Yes

Complications for the mother?*

Yes

Currently breastfeeding?*

Yes

Date

Caesarean?

Yes

Complications for the mother?

Yes

Currently breastfeeding?

Yes

Date

Caesarean?

Yes

Complications for the mother?

Yes

Currently breastfeeding?

Yes

Date

Caesarean?

Yes

Complications for the mother?

Yes

Currently breastfeeding?

Yes

Date

Caesarean?

Yes

Complications for the mother?

Yes

Currently breastfeeding?

Yes

Date

Caesarean?

Yes

Complications for the mother?

Yes

Currently breastfeeding?

Yes

Have you ever had miscarriage(s)?*

Yes

Date (approximate)*

Did you need curettage?*

Yes

Complications?*

Yes

Date

Did you need curettage?

Yes

Complications?

Yes

Date

Did you need curettage?

Yes

Complications?

Yes

Date

Did you need curettage?

Yes

Complications?

Yes

Have you ever had ectopic pregnancie(s)?*

Yes

Date (approximate)*

Treatment*

Medical (methotrexate)

With instruments (surgical)

Other

Date (approximate)

Treatment

Medical (methotrexate)

With instruments (surgical)

Other

Have you ever had abortion(s)?*

Yes

Year and where*

Numbers of weeks*

Type of procedure*

By instruments (surgical)

Medical (by medications)

Complications?*

Yes

Year and where

Numbers of weeks

Type of procedure

By instruments (surgical)

Medical (by medications)

Complications?

Yes

Year and where

Numbers of weeks

Type of procedure

By instruments (surgical)

Medical (by medications)

Complications?

Yes

Year and where

Numbers of weeks

Type of procedure

By instruments (surgical)

Medical (by medications)

Complications?

Yes

Year and where

Numbers of weeks

Type of procedure

By instruments (surgical)

Medical (by medications)

Complications?

Yes

Year and where

Numbers of weeks

Type of procedure

By instruments (surgical)

Medical (by medications)

Complications?

Yes

Have you ever had a pap test (test Papanicolaou - cytology - cervical cancer screening)?*

Yes

Date of last one*

Result

Have you ever had an abnormal result in the past?*

Yes

Date

Diagnosis

Treatment

Where?

Medical history

Have you ever had surgeries?*

Yes

Which one / which ones?

Do you suffer or have you ever had :

Asthma?*

Yes

Year of diagnosis

Treatment

Sleep apnea?*

Yes

Year of diagnosis

Treatment

A pulmonary embolism?*

Yes

Year of diagnosis

Cause

Treatment

A thrombophlebitis?*

Yes

Year of diagnosis

Cause

Treatment

A stroke or a TIA?*

Yes

Year of diagnosis

Treatment

A coagulation problem?*

Yes

Year of diagnosis

Accurate diagnosis

Treatment

Epilepsy?*

Yes

Year of diagnosis

Treatment

Migraines?*

Yes

Year of diagnosis

Treatment

With aura?

Yes

Heart problems (e.g. heart attack, valvulopathy, cardiomyopathy, etc.)?*

Yes

Year of diagnosis

Accurate diagnosis

Treatment

High blood pressure?*

Yes

Year of diagnosis

Treatment

High cholesterol?*

Yes

Year of diagnosis

Treatment

Diabetes?*

Yes

Type?

Type 1

Type 2

During pregnancy

Year of diagnosis

Treatment

A liver disease?*

Yes

Year of diagnosis

Accurate diagnosis

Treatment

Hypothyroidism?*

Yes

Year of diagnosis

Treatment

An autoimmune or inflammatory disease (eg : lupus, Crohn's, etc.)?*

Yes

Year of diagnosis

Accurate diagnosis

Treatment

Severe anemia?*

Yes

Year of diagnosis

Cause

Treatment

Breast disease?*

Yes

Year of diagnosis

Accurate diagnosis

Treatment

A cancer?*

Yes

Year of diagnosis

Accurate diagnosis

Treatment

Depressive symptoms?*

Yes

Year

Treatment

Anxiety?*

Yes

Year

Treatment

Other mental health issues?*

Yes

Year

Diagnosis

Treatment

Acne?*

Yes

Year

Treatment

PCOS (polycystic ovary syndrom)?*

Yes

Year

How many periods do you have per year ?

Porphyria? Adrenal insufficiency? Or OTHER?*

Yes

Year

Diagnosis

Treatment

Year

Diagnosis

Treatment

Year

Diagnosis

Treatment

Have you ever had a sexually transmitted disease?*

Yes

Which one(s)?

Chlamydia

Gonorrhea

Herpes

Genital warts (condylomas)

Trichomonas

Syphilis

Other

Date (chlamydia)

Treatment (chlamydia)

Date (gonorrhea)

Treatment (gonorrhea)

Date (herpes)

Treatment (herpes)

Date (condylomas)

Treatment (condylomas)

Date (trichomonas)

Treatment (trichomonas)

Date (syphilis)

Treatment (syphilis)

Date (other)

Treatment (other)

Have you been vaccinated against HPV (Gardasil, Cervarix)?*

Yes

When was your last STI screening?*

I have never had a screening

I do not remember

Date to choose

Date*

Result*

Treatment (if applicable)

In order to guide screening, if necessary, how many sexual partners have you had in the last year?

Do you know your blood type?*

Yes

Which one?

A+

B+

AB+

O+

A-

B-

AB-

O-

Do you have allergies?*

Yes

To medication?*

Yes

Drug name*

Type of reaction*

Drug name

Type of reaction

Drug name

Type of reaction

Drug name

Type of reaction

Drug name

Type of reaction

Other allergy(s)?*

Yes

Which one(s)?*

Type of reaction*

Do you take any medication(s)?*

Yes

Which one(s)?

Do you take one or more natural products (eg St. John's wort)?*

Yes

Which one(s) ?

Lifestyles

Do you smoke cigarettes or vape?*

Yes

How many cigarette(s) per day?*

If you come for a procedure requiring anesthesia :

Do you regularly drink alcohol?

Never

Occasionally

Frequently

Do you regularly use drugs (including cannabis)?

Yes

Contraceptive history

Have you ever used a contraceptive method (e.g. : condom, pill, IUD, etc...)?*

Yes

Which one(s)?*

At the present time, do you use any contraceptive method (e.g. : condom, pill, IUD, etc...)?*

Yes

Which one(s)?

Since when?*

Do you plan to travel in the next 14 days? If yes, where and for how long?*

Are there any concerns you would like to share with us (will be consulted the day of the appointment)?