Reproductive Reflexology
Pre-Conceptual Questionnaire

All information provided in this document is treated in the strictest confidence and will not be divulged to any other practitioner, without your permission.

Note: Please provide copies of any fertility tests and/or semen analysis results at your scheduled consultation.
Privacy Declaration: The contents of this questionnaire will not be copied, reproduced or otherwise circulated without my prior consent, in any form.

Complete the Pre-Conceptual Questionnaire and I will be in contact with you upon receipt.

FEMALE PARTNER










GENERAL PRACTITIONER


MALE PARTNER










GENERAL PRACTITIONER


FERTILITY INFORMATION

Fertility Difficulties? YesNo



Previous Fertility Treatments:

  IUI: YesNo
 IVF: YesNo
ICSI: YesNo

FEMALE - GYNAECOLOGICAL HISTORY

Do you or have you suffered from any of the following?
(Please check any that apply either currently or previously)

Amenhorrhoea (no periods)Irregular PeriodsAnovulationLow back PainMalformed WombOvulation PainCystitisOvarian CystsEndometriosisAndometriosisFallopian Tube IssuesPain on IntercoursePainful PeriodsPMSThrushFibroidsGenital UlcersWater RetentionVaginal Discharge/Burning/Irritation

Have you been checked or previously treated for?
(Please check any that apply)

AIDSGonorrheaB. StrepHerpesCandidaCervical ErosionChlamydiaGenital WartsSyphilisTrichomonas

Any further information about present/past fertility issues?

MALE - FERTILITY STATUS

Have you had a semen analysis? YesNo




Have you had any of the following?
(Please check any that apply)

MumpsTesticular CancerNon-specific urethritisVaricoceleRubellaVasectomy Reversal

Have you been checked or previously treated for?
(Please check any that apply)

AIDSGonorrheaB. StrepHerpesCandidaChlamydiaGenital WartsSyphilisTrichomonas

Any further information about present/past fertility issues?

CONTRACEPTION INFORMATION

CoilOCPDiaphragmCondomFemale CondomSpongeNatural Family PlanningPersona

FEMALE – CURRENT MEDICAL TREATMENT

Please check any that apply

AntidepressantsPainkillersDiureticsSleeping TabletsSteroidsLaxativesTranquillizers

Do you smoke? YesNo

Do you drink? YesNo

Do you do drugs? YesNo

MALE – CURRENT MEDICAL TREATMENT

Please check any that apply

AntidepressantsPainkillersDiureticsSleeping TabletsSteroidsLaxativesTranquillizers

Do you smoke? YesNo

Do you drink? YesNo

Do you do drugs? YesNo

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