Fertility Consultation FormPlease enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Date of BirthAddressPhone *GP AddressYour WeightSmokerYesNoIf Yes How Many Per DayAlcoholYesNoUnits Per DayAge of Menstrual OnsetAware of OvulationYesNoCycle Frequency/ ? DaysRegularRegularIrregularConsistency of BleedSpotting - BeginningSpotting - Mid CycleLength of Period in DaysColour of BleedBright RedBrownDark RedClotsIntermenstrual BleedingYesNoSmear History: Upto DateYesNoColpscopyYesNoIf Yes: ResultsCIN1CIN2CIN3Any Further Follow Up RequiredYesNoPainful PeriodsYesNoPainful OvulationYesNoIssuesPCOSEndometrosisFibroidsLow back painFrequent UrinationContraception MethodHave you managed to conceive naturally before?Miscarriages? Details of weeks 1 or moreHow many children do you have?Any gynaecological problems?Any sexually transmitted infectionsYouPartnerPID / ChlamydiaSTIs/MumpsHow long have you been trying for a babyAny investigations? HSG etcTreatment Cycles IVF/ICSI. If yes please state how manyHas your partner had a Sperm Analysis performed? Result?NormalLowNo SpermMorphologyMotilityAny other relevent medical history including recent surgeryDetails of supplements or medicationWould you like to join our Email list to receive news and special offers?YesNoConsent *YesNoI confirm to the best of my knowledge the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. The treatment I am about to receive has been explained to me and I give my consent to reflexology. Under GDPR this information will be retained securely by me and will be held for 8 years as per recommendations of my insurance company.Signature *Send Form
