Dr Sylvia Ross 

and

Dr Rebecca Mackenzie-Proctor

Registration Form 

CLIENTS INFORMATION (OVARIES/UTERUS)

Client Details

Title

First Name (as per Medicare)

Last Name (as per Medicare)

Date of Birth

Preferred Name

Biological Sex

Pronouns

Relationship Status

SingleDe FactoMarried Same Sex PartnerOther

Occupation

Height

Weight

Do you require translation services?

YesNo

Ethnicity

ATSI

AboriginalTorres Strait Islander

Main Concern for Consultation

Contact Details

Mobile Phone

Email

Address (as per Medicare)

Street addressStreet address line 2

City

StatePlease selectACTNSWNTQLDSATASVICWA

Postcode

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Medicare/Insurance Details

Medicare Number

Position

Expiry

Private Health Provider

Policy Number

Emergency Contact

Full Name

Next of kin - Relationship

PartnerMotherFatherSiblingFriendOther

Mobile

Referral Details

Usual GP’s Name

Clinic Name

How Did You Hear About Us

Interested Parties (list any additional clinicians who should receive the results)

Please Upload Referral and Results

Browse

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Menstrual And Reproductive History

Age At First Period

Date Of Last Period

Are Your Periods Regular

YesNo

Average Cycle Length (Days)

Period Duration (Days)

Painful Periods

MildModerateSevere

Other Pain

UrinationIntercourse BowelsOther

Do You Have

Heavy Periods PMS/PMDD (Mood Changes With Period) Vaginal Discharge (A Concern To You)

Have You Ever Used

COCP POP Implanon IUCD HRT Other:

If so, What and When

Are You Currently Taking Any Hormones

YesNo

If so, What and When

Have You Ever Been Diagnosed with

PMOS Adenomyosis Endometriosis Fibroids Other Gynaecological ConcernsNone

If other Gynacological Conerns

Are You Concerned About Being Perimenopausal Or Menopausal

YesNo

Do You Suffer From

AcneExcess Hair Growth (Face, Chest, Abdomen) Scalp Hair Thinning

Do You Suffer From

Hot Flush/Sweats Sleep Disturbance Vaginal Dryness Incontinency/Prolapse Brain Fog Joint Stiffness Other Concerns, details:

Any Treatment To Your Cervix

YesNo

If Yes, Any Abnormalities or Treatment?

Date

Have You Ever Had A Cervical Smear

YesNo

Year Of Last Smear

Fertility And Pregnancy History

Are you actively trying to conceive?

YesNo

When Did You Start

Have you had fertility treatment previously?

YesNo

Details And Outcome

Have you ever been pregnant?

Yes No

Total Pregnancies

Live Births

Miscarriages

Terminations

Pregnancy outcomesLive BirthMiscarriageStillbirthEctopic PregnancyTermination of Pregnancy

Date

Complications (i.e. Hypertension, Pre-Eclampsia, GDM Bleeding)

Pregnancy outcomesLive BirthMiscarriageStillbirthEctopic PregnancyTermination of Pregnancy

Date

Complications (i.e. Hypertension, Pre-Eclampsia, GDM Bleeding)

Pregnancy outcomesLive BirthMiscarriageStillbirthEctopic PregnancyTermination of Pregnancy

Date

Complications (i.e. Hypertension, Pre-Eclampsia, GDM Bleeding)

Pregnancy outcomesLive BirthMiscarriageStillbirthEctopic PregnancyTermination of Pregnancy

Date

Complications (i.e. Hypertension, Pre-Eclampsia, GDM Bleeding)

Do You Have Children From A Previous Relationship

YesNo

Previous Fertility Treatmemt

YesNo

If Yes, Treatment Type

Ovulation InductionIUIEgg FreezingIVFFrozen Embryo Transfer

Previous Clinic/Doctor/Treatment

Medical History

Past/Previous Medical Conditions

Yes No

Details

Ongoing Medical Conditions

YesNo

Details

Do You Suffer From

Asthma Thyroid Diabetes Migraine (With/Without Aura)IBS Blood Pressure Other

If other, provide details (Type, Year, Details)

Previous Surgeries (Incl. Reproductive)

Yes No

Type of Surgery

Year

Any Complications

Type of Surgery

Year

Any Complications

Mental Health Conditions Such As ADHD, Anxiety, Depression, Bipolar, Other

YesNo

Details

Are there any experiences (for examplae - Past Trauma, PTSD) that may make physical examination uncomfortable or require special care or consideration from the doctor

YesNo

Please let us know how we can help make you more comfortable

Medications And Supplements

Current Medications

Vitamins/Supplements

Allergies (Medications, Latex, Etc.)

Environmental Exposure

Exposure To Chemicals/Radiation/Heavy Lifting/High Stress

YesNo

Details

Family History

Inherited/Genetic Disorders In Family

YesNo

Details

Health Issues In Relatives (Diabetes, Heart Disease, High Blood Pressure, Cancers, Autoimmune Conditions, Endometriosis, Infertility)

YesNo

Details

Early Menopause In Family

YesNo

Lifestyle Factors

Do You Smoke

YesNoEx Smoker

How Much

Alcohol Consumption

YesNo

How Often

Recreational Drugs

YesNo

Type

Frequency

Any Food Restrictions

YesNo

Details

Do You Drink Caffeinated Drinks

YesNo

If Yes, How Often

What Type

CoffeeTea (Including Green Tea)Energy Drinks Chocolate

Do You Exercise

YesNo

If Yes, What Type And How Often

Sexually Transmitted Infections (STI) And Sexual Health

Have You Been Sexually Active

YesNoPrefer not to say

History Of STIs

YesNo

Which

Treated

YesNo

Any Past Pelvic Inflammatory Disease (PID)

YesNo

Consent

I am aware that artificial intelligence (AI) may be used for note-taking during consultations.

I understand that my personal and health information will be kept confidential and used solely for the purposes of my care and treatment in compliance with VIC Health and Privacy legislation.

I consent to my information being shared with treating doctors, nurses, embryologists, and other relevant healthcare providers involved in my care.

I understand my records are kept confidential and securely stored in compliance with VIC Health and Privacy legislation.

I understand it is my responsibility to notify of any change to or correction of my personal information, inlcuding relationship status.

I understand I may request access to my health information by contacting the clinic in writing.

I consent to being contacted by the clinic via phone, email, or SMS regarding appointments, results, and treatment updates.

I consent to the use of my de-identified data for clinical audit or quality improvement purposes.

I understand that a pelvic ultrasound (internal) is a standard diagnostic procedure used to evaluate reproductive organs and monitor treatment. I consent to the performance of pelvic ultrasounds by qualified clinic staff or sonographers.

I acknowledge that I am responsible for payment of any applicable consultation and treatment fees.

If applicable, I consent to relevant medical information being shared between myself and my partner for the purpose of joint fertility treatment.

I understand that I may withdraw or modify my consent at any time by notifying the clinic in writing.

I confirm that the information I have provided is accurate and complete to the best of my knowledge. *

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