Download Couple Fertility consultation

Couple Consultation
Female Partner Questionnaire
Personal details
Name
Address
Telephone
Email
Date of birth
Occupation
Marital Status
Doctor’s name
Surgery Address
Telephone number
Weight
Age
Time together
Height
Reason for visit
What is your primary concern?
When did it first occur?
Describe any stress occurring at the time of onset?
Does this condition interfere with
 Sleep - Yes/No
 Work – Yes/No
 Relationships – Yes/No
Medical History
Do you suffer from/been diagnosed with any of the following? If yes then please give details.
 PCOS
 Endometriosis
 Fibroids
 Fallopian tubes issues
 Thrush
 Genital Ulcers
 Vaginal discharge/burning/irritation
 Ovarian cyst
 POF (Premature Ovarian Failure)
 Low AMH
 Gynaecological problems
Have you been previously treated for?
 Aids
 B Strep
 Candida
 Chlamydia
 Syphilis
 Gonorrhoea
 Herpes
 Cervical Erosion
 Genital Warts
Arty Thukral  Amarisa Footsteps  [email protected]  07824 643182
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Couple Consultation
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Trichomonas
Have you ever had any abdomen/lower back surgery?
Have you ever had any falls or injuries to the sacrum, tailbone or head?
Details of any health problems are you still experiencing?
Details of any medication you care currently taking?
Details of any other supplements, remedies or herbs?
Menstrual Health
At what age did you start your period?
What was this experience for you?
Did you ever experience irregular cycles?
Currently how long is each cycle?
How many days is your period?
Are your periods light, average, or heavy?
Are your period ever painful?
Do you experience nay pre-menstrual symptoms?
Do you use tampons, sanitary pads, moon cups or others?
Do you ovulate every month?
Are you aware of your fertile time?
Do you monitor your cervical mucus?
Do you chart your temperature?
Symptoms prior to and during menstruations
Do you suffer from any of the below:
 Lower back ache – Yes/No
 Headaches – Yes/No
 Dizziness – Yes/No
 Changes in bowels – Yes/No
 Painful/numbness in left leg – Yes/No
 Painful/numbness in right leg – Yes/No
 Dark thick blood at beginning of menstruation – Yes/No
 Dark thick blood at end of menstruation – Yes/No
 Blood clots - Yes/No
 Cramps left side - Yes/No
 Cramps right side - Yes/No
 Heaviness or pressure in the lower pelvis- Yes/No
 Dragging sensation - Yes/No
 Increased urination - Yes/No
Symptoms currently experiencing
Do you suffer from any of the below:
 Varicose veins left leg – Yes/No
Arty Thukral  Amarisa Footsteps  [email protected]  07824 643182
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Couple Consultation
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Varicose veins right leg – Yes/No
Bladder infection – Yes/No
Bladder weakness– Yes/No
Frequent urination – Yes/No
Cold hands or feet – Yes/No
Anxiety/Depression – Yes/No
Trouble with sleep onset – Yes/No
Trouble with sleep maintenance - Yes/No
Tightness in chest - Yes/No
Difficulty breathing into abdomen - Yes/No
Difficulty experiencing an organism – Yes/No
Digestive complaints
Do you suffer from any of the below:
 Constipation – Yes/No
 Diarrhoea – Yes/No
 IBS – Yes/No
 Formed bowel movements (sausage like)– Yes/No
 Loose bowel movements – Yes/No
 Hard bowel movements – Yes/No
 Non-formed movements (pellets) – Yes/No
 Abdominal pain left side – Yes/No
 Abdominal pain right side - Yes/No
Fertility History
Have you seen your GP about your fertility?
What diagnosis did you receive?
How long have you been trying for a baby?
Have you ever been pregnant?
Have you ever experienced a miscarriage?
If yes, please provide details of when and at what stage of pregnancy?
Do you or your partner have any children?
Please give details such as name and age
Have you even terminated a pregnancy?
Is this termination confidential?
What tests and investigations have you had? e.g. FSH, progesterone, scans
Fertility clinic
Clinic name
Consultant’s name
Arty Thukral  Amarisa Footsteps  [email protected]  07824 643182
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Couple Consultation
What fertility treatments have you had? e.g. IVF, IUI, Clomid
Date
Treatment
Clinic
Outcome
What complementary treatments have you had for fertility? e.g. Acupuncture
Lifestyle
Do you smoke?
How many a week?
Do you drink?
How many units a week?
Do you use drugs?
Give details
How many hours do you sleep on average per night?
Do you exercises?
What is your diet like?
Have you seen a nutritionist?
How many hours a week do you work?
How much time do you spend commuting every day?
What are your hobbies?
What is your source of relaxation?
Family history
Is there any history of fertility problems in your family?
Is there any history of miscarriage?
Are your parents still alive?
Are your parents still married?
How many brothers and sisters do you have?
What is your position in the family? (e.g. oldest, youngest)
Do any of your siblings have children?
Parent’s background
Describe any details of your mother’s background during her birth, significant life stories that influenced
her life. This can include, previous losses, abuse, unresolved conflicts, illnesses or addictions.
Describe any details of your father’s background during his birth, significant life stories that influenced
her life. This can include, previous losses, abuse, unresolved conflicts, illnesses or addictions.
What was your parent’s relationship before and around the time of your birth and conception?
Your experiences during the early stages
Arty Thukral  Amarisa Footsteps  [email protected]  07824 643182
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Couple Consultation
Describe how it was when you were in your mother’s womb?
Describe how your birth was?
Describe your bonding and newborn period
Describe yourself as a baby
The birth of your child
Describe the period during the conception of your first child? (If more than one child then describe for
each child)
Describe the period during the birth of your first child? (If more than one child then describe for each
child)
Birth of your future baby
How do you feel about the birth of your child?
Have you thought of where and how you would like to give birth? Explain the reasons for your choices.
Arty Thukral  Amarisa Footsteps  [email protected]  07824 643182
5
Couple Consultation
Male partner questionnaire
Personal details
Name
Address
Telephone
Email
Date of birth
Occupation
Doctor’s name
Surgery Address
Telephone number
Weight
Age
Height
Medical History
Have you had a semen analysis ? Y/N
Dates:
Count (in millions):
Percentage Normally Formed Sperm:
Percentage Motile Sperm:
Have you been previously treated for?
 Aids
 B Strep
 Candida
 Chlamydia
 Syphilis
 Gonorrhoea
 Herpes
 Genital Warts
 Trichomonas
Details health problems have you had in the past
Details of any health problems are you still experiencing?
Details of any medication you care currently taking?
Details of any other supplements, remedies or herbs?
Lifestyle
Do you smoke?
How many a week?
Do you drink?
How many units a week?
Do you use drugs?
Give details
How many hours do you sleep on average per night?
Do you exercises?
Arty Thukral  Amarisa Footsteps  [email protected]  07824 643182
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Couple Consultation
What is your diet like?
Have you seen a nutritionist?
How many hours a week do you work?
How much time do you spend commuting every day?
What are your hobbies?
What is your source of relaxation?
Family history
Is there any history of fertility problems in your family?
Is there any history of miscarriage?
Are your parents still alive?
Are your parents still married?
How many brothers and sisters do you have?
What is your position in the family? (e.g. oldest, youngest)
Do any of your siblings have children?
Parent’s background
Describe any details of your mother’s background during her birth, significant life stories that influenced
her life. This can include, previous losses, abuse, unresolved conflicts, illnesses or addictions.
Describe any details of your father’s background during his birth, significant life stories that influenced
her life. This can include, previous losses, abuse, unresolved conflicts, illnesses or addictions.
What was your parent’s relationship before and around the time of your birth and conception?
Your experiences during the early stages
Describe how it was when you were in your mother’s womb?
Describe how your birth was?
Describe your bonding and newborn period
Describe yourself as a baby
The birth of your child
Describe the period during the conception of your first child? (If more than one child then describe for
each child)
Describe the period during the birth of your first child? (If more than one child then describe for each
child)
Birth of your future baby
How do you feel about the birth of your child?
Have you thought of where and how you would like to your partner to give birth? Explain the reasons for
your choices.
Arty Thukral  Amarisa Footsteps  [email protected]  07824 643182
7
Couple Consultation
Thank you for providing this information, please be reassured that it will be treated with the
greatest confidence, and will only be used in helping you to achieve your goal of conception
and parenthood.
Arty Thukral  Amarisa Footsteps  [email protected]  07824 643182
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