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.