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By John Fry

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Medical aspects of pre-conceptual care: - blood test for Rubella status blood pressure weight height urine analysis blood profile cervical smear Details of the health of both partners: - general health lifestyle contraception eating habits The above information provides a baseline from which to assess changes during pregnancy. 36 SPECIFICS WELL-WOMAN CLINIC The practice needs to agree that it wishes to run a well- woman clinic, that there are the resources for such a clinic and the facilities available to undertake the clinic.

Have you tried to give up? Have you cut down? (Yes) when? and by how many? What is the maximum number per day you have ever smoked? Alcohol: How much alcohol do you drink per week: Height: What is your height? Weight: What is your weight? 48 beer: wine: spirits: SPECIFICS Would you say you are underweight? Would you say you are overweight? Have you lost weight recently? How much? . Have you gained weight recently? How much? . Family history Do you or any of your family or close relatives have or had any of the following: Yes No Details Diabetes High blood pressure Heart attack Stroke Epilepsy or fit Asthma Skin disease Nervous disorders Allergies Congenital diseases Cancer Kidney disease Immunisation history: Please indicate if you have been immunised against the following illnesses, giving details of last immunisation: German measles Influenza Measles Mumps Polio Tetanus Typhoid Whooping cough 49 TIlE SCREENING HANDBOOK Women only: Periods: At what age did your periods start?

1. Do you consider you are in good health? 2. Is there a family history of: 3. Do you smoke? If YES how many do you smoke a day? Have you tried to stop? Do you wish to stop? YES/NO 4. Do you drink alcohol? If YES how many units do you drink a day? (half pint of lager or single spirit measure = iunit) YES/NO 5. Do you self-examine your breasts regularly? YES/NO 6. Menstrual history - Do you have any period problems? - Age of starting periods - Number of days of bleeding - Period interval (1st to last day) - Any change in cycle - Date oflast period (for appropriate appointment) 7.

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