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Fertility Questionnaire

Fertility Questionnaire

Conception and Menstrual History

Have you been pregnant before?
Do you have a history of miscarriage?
Do you have any diagnosed gynaecological conditions (including fibroids, endometriosis, PCOS, PCO, progesterone deficiency or estrogen dominance, low egg quality, low AMH, thin uterine lining, ovarian cysts)?
Do you keep a Basal Body Temperature Chart?
If yes, please email your 2 most recent charts or bring them to your appointment.
Do you test for ovulation (ovulation kits or Maybe Baby)?
If you do test, do you receive a positive result (the test line MUST be darker than the control or obvious ferning with a Maybe Baby)?
Do you have a regular cycle?
Please tick any of the following that you commonly experience in relation to menstruation:

Assisted Reproduction

General Health

Do you regularly work more than an 8hr day?
Would you consider your job generally stressful?
Do you feel you get ‘sick’ (colds, flus,etc) more often than normal?
Please select one option for each of the following.