Cervical screening pre-appointment assessment

Date of last menstrual period: *

Please use date format: DD/MM/YYYY

Are you experiencing any unusual discharge? *

Yes

No

Are you experiencing any bleeding after sex? *

Yes

No

Are you experiencing any bleeding between periods? *

Yes

No

Are you experiencing any bleeding after the menopause? *

Yes

No

Do you have a coil inserted for contraception? *

Yes

No

Are you on HRT? *

Yes

No

Any other comments regarding the above questions:

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