Patient Information Form

If you have any problems or questions, please contact us.

"*" indicates required fields

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Patient Information

Name*

Prefix First - as per your Medicare card Last - as per your Medicare card

Date of Birth*

Partners Name

First Last

Contact Address*

Street Address Suburb State Postal Code Country

Contact Number*

Email*

Occupation*

Medicare Information

If no Medicare, please write N/A in required fields

Medicare Number*

Medicare Reference*

Expiry Date*

In Case of Emergency

Next of Kin or Emergency Contact

Name*

First Last

Relationship*

Telephone number*

Scan Type

Please select your Scan type:*

Obstetric (Pregnant) or Gynaecology (Not-pregnant)

Obstetric

Gynaecology

OBSTETRIC ULTRASOUND - Patient Screening Information

Current Pregnancy

Due Date (if known)*

Is the first day of the Last Menstrual Period (LMP) known?*

Yes

N/A

First Day of last menstrual period (LMP)*

Height (cm)*

Weight (kg)*

Ethnicity (Required for First Trimester Screening)*

If other,*

Have you had a positive pregnancy test?*

Yes

Please select*

Blood Test

Urine Test

Is this pregnancy a natural conception?*

Yes

Fresh/Frozen?*

Fresh Cycle

Frozen Cycle

What was the date of egg collection?*

If this was an assisted pregnancy, was it*

Donation of your own egg?*

Yes

Donor's DOB/age at donation?*

Number of Embryos transferred?*

Date of Embryo transfer?*

Day 3 or Day 5 Embryo at transfer?*

Did you have preimplantation screening/diagnosis performed?*

Yes

If Yes, what screening/diagnosis?*

Have you had any scans for this pregnancy?*

Yes

If Yes, where and how many weeks were you at the time?*

Have you had NIPT?*

Yes

Please Select*

Obstetric History

How many times have you been pregnant (including this pregnancy)?*

Number and gestation of Live births*

Please list

Date of Birth (Start with the most recent first)

Birth Weight (kg)

Delivery (Vaginal/Caesarean section)

Gestation (weeks)

Number and gestation of Miscarriages/Stillbirth*

Number and gestation of Termination of pregnancies*

Number of Ectopic pregnancies*

Previous pregnancy complications

(Including cervical incompetence, abruption, preterm delivery, preterm rupture membranes, congenital problems)

Other Screening Information

Do you have any allergies? (eg. latex)*

Yes

If Yes, what allergy?*

Are you on any medications/drugs during this pregnancy?*

Yes

If Yes, what Medications/drugs?*

Do you have any medical conditions or known infections?*

Yes

If Yes, what condition or infection?*

Do you have a family history for a chromosomal or congenital condition?*

Yes

Please explain*

Have you smoked during this pregnancy?*

Yes

Do you have Diabetes?*

IDDM

NIDDM

Gestational (currently)

Gestational*

Diet

Metformin

Insulin

Pre-eclampsia in previous pregnancy, if any*

Yes

N/A

Growth restriction in previous pregnancy, if any*

Yes

N/A

Do you have (any of the following):*

Chronic high blood pressure

Systemic lupus erythematous (SLE/lupus)

Antiphospholipid syndrome

Family history (mother) of pre-eclampsia in pregnancy

N/A

Other

Have you had any complications during this pregnancy? (E.g. pain / bleeding etc)

Do you have any concerns?*

Yes

If Yes, what concerns?*

GYNAECOLOGICAL ULTRASOUND

Reason for Ultrasound:*

Is the first day of the Last Menstrual Period (LMP) known?*

Yes

N/A

First Day of Menstrual Period (LMP)*

Weight (kg)*

Post-Menopausal

Age at Menopause

HRT

Yes

Type

Menstrual Cycle

Do you still have a Menstrual period?

Yes

Please select*

Regular

Irregular

Length of usual cycle?*

Contraception:

Yes

Type

(OCP, Mirena, Tubal Ligation)

Cycle

Regular

Irregular

Length of Cycle

From (Days) To (Days)

Length of Bleeding

From (Days) To (Days)

Flow

Light

Normal

Heavy

Painful?

Yes

Usual pain relief?

Other

Pregnancy History

Have you had any previous pregnancies?*

Yes

Number of Live Births

Vaginal

Caesarean

Miscarriages

Ectopic

Termination

Previous pregnancy complications?

Previous Gynaecological Surgery

Please list any previous surgeries

Surgery

Year

Details

Add multiple surgeries by clicking on the + button

Family history of gynaecological cancer?

Yes

Details*

Previous Ultrasound examinations?

Yes

Where When

(Please bring reports)

Do you have any allergies? (eg. latex)*

Yes

If Yes, what allergy?*

Any concerns?*

Transvaginal ultrasound is routinely performed as part of a typical gynaecological assessment. To obtain the information that is required for your care, you may be offered a transvaginal ultrasound. Transvaginal examinations are always performed with discretion at QUFW. Please advise the sonographer if you have any concerns regarding this. The above information is correct.

Do you give consent to have a transvaginal ultrasound if required*

Yes, I consent

Signature

Date*

For optimal assessment of early pregnancy, early fetal structures, cervical and placental assessment, transvaginal ultrasound is routinely performed at QUFW. This allows enhanced resolution when compared with transabdominal scanning. Please advise your sonographer if you have any concerns regarding this.

Imaging

The equipment at QUFW is of the highest standard and enables our sonographers and doctors to carry out a detailed ultrasound. As a specialist centre we place a high emphasis on the medical component of your ultrasound, depending on individual needs this can be quite time consuming and we apologise if you are kept waiting. We understand that this is an exciting and anxious period of your pregnancy and at QUFW we do our best to ensure you have an enjoyable scan. Our sonographers and doctors will endeavour to get the best 3D images of your baby(s) as possible. It is important to be aware that many factors can vary image quality i.e., position of your baby, maternal BMI, uterine position placental position and amount of amniotic fluid present. QUFW uses a cloud-based way of image file sharing called Tricefy. This is complimentary for our obstetrics patients. No personal filming of the scan or staff member is allowed unless authorised.

Do you consent to your de-identified images being used for teaching, education, scientific communication purposes?

Yes

Do you consent to your de-identified images being used for social media?

Yes

I want my ultrasound images delivered electronically?*

Yes

If no, Please be advised that you will not be receiving any images.

I authorize the sending of images during my pregnancy

I have read, understand, and agree to this disclaimer

I will have access to my images for 90 days from my exam date

It is highly recommended that you download and save your images on your phone or other device as the link will expire at the end of 90 days.

Name*

First Last

Mobile Number*

Date*

Click here To view the Tricefy Disclaimer and Authorisation, or please visit their website www.triceimaging.com

Privacy

By attending the practice and signing below, you agreed to the QUFW Group collecting, using and disclosing your personal and health information in accordance with our Patient Privacy Policy (available on our website or at reception). You are not obliged to provide any of the requested information, however if you do not do so, we may not be able to treat you.

The above information is true to the best of my knowledge.*

Agree

Patient to check (or Parent/Guardian if a minor)

Date*