Fertility Detox Questionnaire PERSONAL DETAILS : Please give us a little bit of information about you...Name :*Date of Birth :* MM slash DD slash YYYY Age :*Occupation :Marital Status :How long have you and your partner been together?MEDICAL PRACTITIONERSName of Fertility Clinic :Consultant's Name :FERTILITY HISTORY : Please help us by providing a little bit of detail regarding your fertility historyHave you seen your GP about your fertility?* Yes No If so, what diagnosis did you receive?How long have you been trying for a baby?*Have you ever been pregnant?* Yes No Have you ever experienced a miscarriage?* Yes No If yes, please provide details of when and at what stage of pregnancyDo you or your partner have any children? If so please provide details (name and ages)Have you ever terminated a pregnancy?* Yes No If yes, is this termination confidential? Yes No What tests and investigations have you had? e.g. FSH, progesterone, scans*What medical treatments have you had for fertility? e.g. IUI, Comid, IVF. Please provide details of any treatments including dates, clinics and outcomes.*What complementary treatments have you had for fertility? e.g. acupuncture*MENSTRUAL HEALTHHave you ever used any form of contraception?* Yes No What contraception and for how long?At what age did you start your periods?*What was this experience like for you?Have you ever experienced irregular cycles?* Yes No Currently, how long is each cycle?*How many days is your period?*What are your periods like?* Light Average Heavy Are your periods ever painful?* Yes No Do you experience any premenstrual symptoms?* Yes No If so please provide some detailsDo you use tampons, sanitary pads, moon cup or other?*Do you ovulate every month?* Yes No How do you know that you are ovulating?*Are you aware of your fertile time?* Yes No Do you monitor your cervical mucus secretions?* Yes No GENERAL HEALTH : Please answer the following questions about your general health giving us much detail as possible.Weight :*Height :*Please select any of the following you have been diagnosed with : PCOS Endometriosis Fibroids Gynaecological problems What health problems have you had in the past?*What health problems are you still experiencing?*Are you taking any medication?*Are you taking any other supplements, remedies or herbs?*SEXUAL RELATIONSHIPDo you experience any difficulties in your sexual relationship?*Has trying for a baby affected your sex life?* Yes No How frequently do you have sex?*FAMILY HISTORY : Please take the time to answer a few questions about your family historyIs there any history of fertility problems in your family?* Yes No Is there any history of miscarriage?* Yes No Is there any history of birth trauma?* Yes No Are your parents still alive?* Yes No Are your parents still married?* Yes No How many brothers/sisters do you have?*What is your position in the family? (e.g. oldest, middle, 4th)Do any of your siblings have children?* Yes No MENTAL HEALTHHave you ever suffered from depression?* Yes No Have you ever suffered from any psychiatric condition?* Yes No Have you ever suffered with addiction?* Yes No LIFESTYLE : And finally please answer the following questions about your general lifestyle.How many hours do you sleep on average per night?*Do you exercise?* Yes No What is your diet like?*Have you seen a nutritionist?* Yes No Do you smoke?* Yes No Do you take any recreational drugs?* Yes No How many hours a week do you work?*How much time do you spend commuting every day?*What are your interests and hobbies?What else do you do to relax? Δ
