Fertility Questionnaire – Female


CLIENT INFORMATION

Your Name         

Partner's Name

Address             

Mobile Phone     

E-mail address  

Skype name  

Date of birth       

Partner date of birth


Please fill in form, tick boxes and add comments if applicable

What is your occupation? Please be specific, list activities

How long have you been trying to conceive?

Cause of infertility (if known)

What frustrates you the most about not being able to fall pregnant?

What do you think is the problem with your menstrual period, if any?

Menstrual Period

How many days is your cycle?

Do you experience any of the following during your period?

Flooding Brown blood Clotting Very light bleeding Pain Bleeding outside of cycle

Do you experience any of the following before your period?

Pain Spotting Tender breast Irritability Headaches Cravings

Do you know when you ovulate? YesNo

Have you been pregnant before? YesNo

If so, with your current partner? YesNo. When?

Have you had any miscarriages? if so, when?

Does your partner have any fertility issues? If so, please describe

Has your partner had a semen analysis done? If so, when?

Are you taking any prescription medication?

Are you taking any supplements (vitamins, minerals, etc.), herbs, homeopathic medicines, etc.?

Have you/or your partner been taking any recreational drugs within the last 2 years? If so, please describe

Have you been on the oral contraceptive pill or had any implants for contraception? If so, when and how long for?

Any adverse reaction such as feeling unwell, weight gain, etc.?

YesNo

Why did you start oral contraceptive pill/implant? Contraception, Acne, PCOS, Pain, etc.

Do you have a history of any of the following infections?
Herpes Chlamydia Venereal Warts Gonorrhea Other

Please tick boxes that apply to you
I have pain during sex I bleed after sex I use lubricants during sex My libido is poor
I have vaginal discharge other than the normal discharge

If so, any smell? What colour?


GENERAL HEALTH

Describe your overall state of health.

Do you consider yourself:
Not very healthyhealthyperfectly healthy

Height: Weight:
Current health problems not related to infertility

How do you rate your energy levels? lowmediumhigh

How often in the last year have you suffered from infections, colds, flu, etc?
Neveroccasionallyfrequently

Have you taken any of these medications within the last 5 years?

Antibiotics - If so, when
Antidepressants - If so, when
Steroid based medication - If so, when
Antihistamines - If so, when or how often
Panadol or other pain medication - If so, when or how often
Other

Environment
Do you use pesticides/herbicides? YesNo
Do you use insect repellent? YesNo
Have you been exposed to chemicals? YesNo
Do you use chemicals on a regular basis, ie. work? YesNo
In the past 2 years have any activities involved frequent contact with chemicals including plastics, paints, new carpets, new car, glues, insecticides, hair chemicals, pest control, etc.? YesNo
If yes, give details

Do you fly frequently? YesNo
Do you have electrical appliances in your bedroom? YesNo
If yes, give details

Hobbies and other activities (please include gardening, sports activities, crafts, etc)

How would you rate your relationship with your partner/husband on a scale of 10?
Not very fulfilling 12345678910 excellent

Do you experience any of the following? Please tick the appropriate box.

Acidity Hairloss
Acne Hay fever
Anemia Headaches Anorexia/Bulimia Herpes Anxiety High/low blood sugar Arthritis High blood pressure
Asthma Insomnia Autoimmune disease Irritable bowel syndrome
Bleeding gums Joint/muscle pain
Bloating Kidney problems (kidney stones, fluid retention)
Blocked Fallopian tubes Leukemia
Blood Pressure (high/low) Liver issues
Bone Spurs Menopausal symptoms
Bowel Problems Migraine
Brittle nails Mouth ulcers
Burping, Reflux Nasal/sinus congestion
Cancer or Tumours: Nausea (during period or random?)
Candida Nervousness
Cholesterol issues Numbness/tingling
Chronic fatigue Palpitations
Cold hands/feet Pelvic inflammatory disease
Colic (Flatulence, wind) Polycystic ovarian syndrome (PCOS)
Constipation Respiratory problems
Cramps (not associated with period) Sciatica
Dandruff Skin conditions (eczema, psoriasis, etc.)
Depression Sleepiness/Tiredness
Diabetes Sweats (excessive)
Diarrhea Teeth problems
Digestive Problems Thrombosis
Endometriosis Thrush
Epilepsy Thyroid problems
Excessive hair growth on face and/or body Urinary tract infections
Eye Problems (Conjunctivits, styes) Vaginal itching
Fibroids Varicose veins
Food or seasonal allergies/hay fever Vertigo (Dizziness)
Fungal conditions Warts
Gall Bladder problems Weight problems
Glandular Fever (now or in the past) Worms
Gout Vaccinations within the last 5 years
Other

Lifestyle/Diet

I drink alcohol I smoke
I regularly drink soft drinks/diet drinks I drink water from the tap (unfiltered)
I drink coffee/tea I microwave my food
I use perfumes/deodorants/antiperspirants I drink less than 8 glasses of water a day
I have take away food more than once per week I have a lot of stress in my life (ie. work, home,)
I crave carbohydrates I crave salty food
I get heartburn/reflux I am vegetarian/vegan

Mental/emotional state

I am very fastidious and like things in order and tidy I am a perfectionist
I cry easilyI am very anxious about falling pregnant
I have many fears and am very anxiousI often feel angry and irritable

Anything else you think I should know? Any other past health issues?