Health Questionnaire 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?