Health Questionnaire HIS 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? 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 Do you have a history of any of the following infections? HerpesChlamydiaVenereal WartsGonorrheaOther 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 tubesLeukemiaBlood 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)Polycystic 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? Sexual function Do you have any erection issues? Yes / No Please provide details if Yes. Do you have any ejaculation issues? Yes / No Please provide details if Yes. Is you hair falling out? (if yes, have you ever used medication for this? Yes / No Please provide details if Yes. Do you have prostate problems? Yes / No Please provide details if Yes. Do you have sperm issues? Yes / No Please provide details if Yes. Do you have testicular problems? (varicocele, pain, etc.): Yes/No Please provide details if Yes.