HyCoSy & SIS Intake Form

Surname

First Name

Preferred Name

Your DOB

Gender

Address

Email **

Mobile

Medicare Number:

Medicare Ref No:

Referring Doctor

Procedure to be performed

HyCoSy – to check the fallopian tubes are open SIS – to check the uterine cavity (shape, polyps, fibroids)

Location of previous pelvic ultrasounds

QDOS Ultrasound Never had a pelvis ultrasound before Other

If Other, where?

MENSTRUAL INFORMATION

The first day of your last period was

Your bleeding lasts for how many days?

Your period starting day is

Regular – like clockwork Fairly regular – within 2-3 days of expected start Unpredictable – varies 4 or more days from the average

Your typical cycle (Day 1 to Day 1 of bleeding) is how many days (give range if unpredictable)

MEDICAL INFORMATION

Are you on the oral contraceptive pill?

No Yes

Do you use any other contraceptive hormones?

No Yes

If Yes, what?

Are you allergic to any antiseptic solutions?

No Yes

If Yes, what?

Have you had recent treatment for a pelvic infection?

No Yes

Do you currently have symptoms of abdominal pain with vaginal discharge or fevers/chills/loss of appetite?

No Yes

Have you had surgery on your cervix? (eg. laser treatment, LLETZ, cone biopsy, suture)

No Yes

Do you become faint during vaginal examinations?

No Yes

Do you become faint during blood tests?

No Yes

PROCEDURE INFORMATION & INFORMED CONSENT
📄 View HyCoSy & SIS Patient Information & Consent Guide (PDF)

Have you read the procedure information on our website?

I acknowledge that I have accessed and reviewed the procedure information. I understand that a physical hard copy will be provided for my review and signature during my clinic visit.

Is there anything else you think we should know about you?

Are there any questions you would like us to answer before an appointment is made?

Privacy
QDOS ultrasound is committed to protecting your privacy according to the Privacy Act. Access to computer records containing your information is restricted to staff, with varying access levels and is password protected. All hard copies of patient documents are disposed of in a secure manner. At times it may be necessary to email or fax your reports to other Medical Practitioners and Hospitals.
** We use the email you provide to forward invoices/receipts, medical reports if requested, and communication regarding appointments at QDOS ultrasound

My Health Record

Do you want your results to go to your My Health Record

Yes No

Attach File Referral if Any (Accepted file types: pdf, jpg. Max. file size: 10 MB.)

QDOS Ultrasound provides specialist obstetric and gynaecology ultrasound performed by highly experienced and motivated doctors and sonographers. The rooms are purpose-built, located on the ground floor at 12 Connolly Street, West Leederville, at the rear of Connolly House, which is on the corner of Connolly and Cambridge Streets, opposite SJOG Hospital Subiaco.

Pregnancy

Patient Resources
Pregnancy Calculator

Gynaecology

Submit Referral & Patient Information here

Contact

Address
12 Connolly St, West Leederville
PERTH – Western Australia 6007

Monday – Friday
8:00 am – 4:45 pm
(strictly by appointment only)