Full Name *
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Conception and Menstrual History How long have you been trying to conceive (TTC)?
Have you been pregnant before?
If yes, do you have any children? Please list their ages:
Do you have a history of miscarriage?
If yes, please detail (weeks of gestation at time of miscarriage, etc.):
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)?
If yes, please detail:
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)?
If yes, what day of your cycle do you receive this positive result normally?
Do you have a regular cycle?
If yes, how many days is your cycle?
If not, please give details about your cycle history:(N.B. Cycle length is calculated from the first day of your last period to the first day of the following period.)
What is the length of your normal period?
Would you say your period is generally light/medium or heavy flow? (light would be having to change tampons or pads about twice a day on the heaviest days, medium would be 3-4 on the heaviest days, heavy would be every 2hrs or more)
Do you experience clotting, if so is it normally small (pea size or smaller), medium (10 cent piece size) or large (50 cent piece or larger)?
Please tick any of the following that you commonly experience in relation to menstruation:
If you experience pain is it before, during and or after your period?
Is the pain sharp (as in stabbing) or dull and achy?
Where do you experience the pain (lower abdomen, lower back, down your legs)?
If yes, how long for in total and when did you finish taking it?
Assisted Reproduction If yes please detail your attempts (when, how many attempts, amount of success i.e. pregnancy):
If you have used IVF, please detail your success with stimulation (how many eggs were collected, fertilised, and how many embryos were viable for transfer)
General Health Are you on any medication (please list)?
Are you on any supplements, vitamins etc (please list)?
Have you had any surgery (please list operations and year)?
On average, how many hours sleep do you get a night?
Would you say you have good quality sleep?
If you have broken sleep, what time do you normally wake?
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?
Out of 10 (10 being the highest) what would you score your energy levels? 0 1 2 3 4 5 6 7 8 9 10
Please list the average amount of exercise you undertake each week:
How many coffees and teas (caffeinated, including green tea) would you have each week?
How much water do you drink on average each day?
How would you rate your diet (excellent, average, could be better, poor)
Out of 10 (10 being the highest) how would you rate your libido? 1 2 3 4 5 6 7 8 9 10
What is your waist measurement? (Please measure your waist at the navel level)
Back Pain (Please indicate neck,mid or lower back)
Pain elsewhere (Please Specify)
Please select one option for each of the following.
Please detail anything else you think may be useful or relevant:
Date
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