Female Fertility Questionnaire 1. What is your first name? 2. What is your surname? 3. What is your age? 4. What is your date of birth (dd/mm/yyyy)? 5. What is your address? 6. Can post be sent to this address? 7. What is your country of birth? 8. What is your occupation? 9. What is your home telephone number? 10. What is your mobile telephone number? 11. What is your contact number at work? (for emergency use only) 12. May we have permission to leave voice messages on your contact numbers (excluding work number)? 13. What is your email address? 14. May we have permission to send out documents and/or information by email to the address supplied above? 15. Doctor's Name 16. Practice Name 17. Address: 18. Do we have permission to contact your G.P.? 19. Are you currently in a relationship? 20. If yes, how many years are you together? 21. Duration of time trying to conceive with current partner (if applicable)? 22. No. of years of unprotected intercourse (with all partners)? 23. Have you had problems conceiving in a previous relationship? 24. Have you ever been diagnosed with a fertility problem? (If yes, please specify in the box below) 25. Have you previously been pregnant? 26. If yes Ectopic PregnancyMiscarriageStillbirthLivebirth 26a. Add any details about previous pregnancies here: 27. Were the pregnancies with your current partner or previous partner? 28. What was the date of the first day of your last period (dd/mm/yyyy)? 29. Are your periods regular? 30. What is your cycle length? 31. For how many days do you bleed? 32. What age were you (approximately) when you had your first period? 33. Do you ever bleed between periods? 34. Do you regularly have painful periods? 35. At what age did your mother go through the menopause? 36. Have you ever had a cervical screening (smear) test? 37. If yes, when was your last smear test? 38. Have you ever had an abnormal cervical smear test? 39. If yes, have you had any treatment for this e.g. LLETZ (laser), cold coagulation etc- please detail in the box below? 40. Have you ever had any sexually transmitted infections? 41. Have you ever had Pelvic Inflammatory Disease (P.I.D.)? 42. Have you ever been diagnosed with tubal problems? 43. Have you used contraception previously, if so, what type and for how long? 44. Have you ever had any uterine problems e.g. polyps, fibroids etc? 45. Please indicate which (if any) gynaecology surgical procedures / other operations you have undergone in chronological order. 46. How often do you have sex? 47. Are you aware of your fertile signs (e.g. cervical mucus secretions)? 48. Have you used any ovulation predictor kits or fertility monitors? 49. Have you used temperature charts? 50. Are you currently timing sex around the time you ovulate? 51. Do either you or your partner have difficulty with arousal or penetration? 52. Do you ever experience pain during or after sex? 53. Do you ever experience bleeding after sex? 54. Do you use lubricant gels or creams during sex? 55. Do you or anyone in your immediate family (parents/siblings) suffer from any of the following? You Parent SiblingAsthmaBirth DefectsCancerCrohn's DiseaseDiabetesEarly MenopauseEndometriosisEpilepsyFibroidsHepatitis or JaundiceHeart MurmurHIVImmune ProblemsInherited ConditionsLupusMultiple Sclerosis or MEPCOSPsoriasis/ EczemaPsychiatric Problems/ DepressionRaised Blood PressureRheumatoid ArthritisSickle Cell DiseaseTay Sach's DiseaseThalassaemiaThyroid ProblemsOtherPreterm labour 56. Are you taking Folic acid tablets?*All women trying to conceive should take 400mcg of folic acid each day ( and continue until the end of the 12th week of pregnancy) to help prevent birth defects (e.g. spina bifida). Folic acid should also be continued while undergoing fertility treatment. 57. Are you currently taking any medication (including painkillers, sleeping tablets, antidepressants, vitamins, herbal or homeopathic remedies)? 58. If yes, please specify below: 59. Are you allergic to any medications, nuts egg or soya? If yes, please give details of the medication and type of reaction. 60. Are you allergic to Latex? 61. Have you ever suffered from depression or high levels of anxiety? 62. Have you ever received treatment from a psychiatrist/ mental health team or been admitted for a psychological issue? 63. Have you ever been affected by violence in your life (physical, mental, emotional or sexual)? 64. Do you have relationship concerns (e.g. partner, parents, family) you wish to discuss? 65. Are you under stress in work or in other areas of your life? 66. Do you experience any sexual difficulties including lack of desire? 67. Have you ever been on or, are currently on, antidepressants, mood stabilisers or anti-psychotic medication? 68. Do you struggle to cope with your (or your partner's) fertility problems? 69. In the last few months have you felt down, depressed or hopeless? 70. If you have answered yes to any of the above, would you like someone to help you with these issues? 71. How many hours per week do you work? 72. How many hours do you sleep, on average, per night? 73. How often do you exercise per week? 74. What type of exercise do you do? 75. Do you smoke cigarettes? 76. If yes, how many cigarettes do you smoke per day? 77. Do you drink alcohol? 78. If yes, how many units of alcohol do you drink per week? 79. Do you take recreational drugs (e.g. marijuana, cocaine etc)? 80. If yes, please specify what drug and how often: 81. What is your weight without your clothes? 82. What is your height, without shoes? 84. Please enter today's date (dd/mm/yyyy) I confirm that all of the information I have provided to staff at My Fertility Check on this form is true and accurate
