Health Questionnaire HERS

Your Name        

Partner's Name 

Address             

Mobile Phone    

E-mail address  

Skype name      

Date of birth      

Partner date of birth 

Please fill in form, tick boxes and add comments if applicable

What is your occupation? Please be specific, list activities

How long have you been trying to conceive?

Cause of infertility (if known)

What frustrates you the most about not being able to fall pregnant?

What do you think is the problem with your menstrual period, if any?

Menstrual Period

How many days is your cycle?

Do you experience any of the following during your period?
FloodingBrown bloodClottingVery light bleedingPainBleeding outside of cycle

Do you experience any of the following before your period?
PainSpottingTender BreastIrritabilityHeadachesCravings

Do you know when you ovulate? YesNo

Have you been pregnant before?YesNo

If so, with your current partner? YesNo
When?

Have you had any miscarriages? if so, when?

Does your partner have any fertility issues? If so, please describe

Has your partner had a semen analysis done? If so, when?

Are you taking any prescription medication?

Are you taking any supplements (vitamins, minerals, etc.), herbs, homeopathic medicines, etc.?

Have you/or your partner been taking any recreational drugs within the last 2 years? If so, please describe

Have you been on the oral contraceptive pill or had any implants for contraception? If so, when and how long for?

Any adverse reaction such as feeling unwell, weight gain, etc.?

YesNo

Why did you start oral contraceptive pill/implant? Contraception, Acne, PCOS, Pain, etc.

Do you have a history of any of the following infections?

HerpesChlamydiaVenereal WartsGonorrheaOther


Please tick boxes that apply to you

I have pain during sexI bleed after sexI use lubricants during sexMy libido is poorI have vaginal discharge other than the normal discharge

If so, any smell?What colour?

GENERAL HEALTH

Describe your overall state of health

Do you consider yourself:
Not very healthyhealthyperfectly healthy

Height:Weight:
Current health problems not related to infertility

How do you rate your energy levels? LowMediumHigh

How often in the last year have you suffered from infections, colds, flu, etc?
NeverOccasionallyFrequently

Have you taken any of these medications within the last 5 years?
Antibiotics - If so, when
Antidepressants - If so, when
Steroid based medication - If so, when
Antihistamines - If so, when or how often
Panadol or other pain medication - If so, when or how often
Other

Environment
Do you use pesticides/herbicides? YesNo
Do you use insect repellent? YesNo
Have you been exposed to chemicals? YesNo
Do you use chemicals on a regular basis, ie. work? YesNo
In the past 2 years have any activities involved frequent contact with chemicals including plastics, paints, new carpets, new car, glues, insecticides, hair chemicals, pest control, etc.? YesNo

If yes, give details

Do you fly frequently? YesNo
Do you have electrical appliances in your bedroom? YesNo
If yes, give details

Hobbies and other activities (please include gardening, sports activities, crafts, etc)

How would you rate your relationship with your partner/husband on a scale of 10?
Not very fulfilling 12345678910 excellent

Do you experience any of the following? Please tick the appropriate box.
AcidityHair lossAcneHay feverAnemiaHeadachesAnorexia/BulimiaHerpesAnxietyHigh/low blood sugarArthritisHigh blood pressureAsthmaInsomniaAutoimmune diseaseIrritable bowel syndromeBleeding gumsJoint/muscle painBloatingKidney problems(kidney stones, fluid retention)Blocked Fallopian tubesLeukaemiaBlood pressure(high/low)Liver issuesBone spursMenopausal symptomsBowel ProblemsMigraineBrittle nailsMouth ulcersBurping, RefluxNasal/sinus congestionCancer or TumoursNausea(during period or random)CandidaNervousnessCholesterol IssuesNumbness/tinglingChronic fatiguePalpitationsCold hands/feetPelvic inflammatory diseaseColic(Flatulence, wind)Poly-cystic ovarian syndrome(PCOS)ConstipationRespiratory problemsCramps (not associated with period)SciaticaDandruffSkin conditions (eczema, psoriasis etc)DepressionSleepiness/TirednessDiabetesSweats(excessive)DiarrheaTeeth ProblemsDigestive ProblemsThrombosisEndometriosisThrushEpilepsyThyroid problemsExcessive hair growth on face and/or bodyUrinary tract infectionsEye Problems(Conjunctivitis, styes)Vaginal itchingFibroidsVaricose veinsFood or seasonal allergies/hay feververtigo (Dizziness)Fungal conditionsWartsGallbladder problemsWeight problemsGlandular Fever (now or in the pas)WormsGoutVaccinations within the last 5 years

Other

Lifestyle/Diet

I drink alcoholI smokeI regularly drink soft drinks/diet drinksI drink water from the tap (unfiltered)I drink coffee/teaI microwave my foodI use perfumes/deodorants/antiperspirantsI drink less than 8 glasses of water a dayI have take away food more than once per weekI have a lot of stress in my life (ie. work, home,)I crave carbohydratesI crave salty foodI get heartburn/refluxI am vegetarian/vegan

Mental/emotional state
I am very fastidious and like things in order and tidyI am a perfectionistI cry easilyI am very anxious about falling pregnantI have many fears and am very anxiousI often feel angry and irritable

Anything else you think I should know? Any other past health issues?